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ARCADIS 1D#: CHAIN OF CUSTODY & LABORATORY Lab Work Order# <br /> Infrastructure,environment,buildings �i ANALYSIS REQUEST FORM Page of AAc///oo3z3 <br /> Contact 8 Company Name: Telephone. PM-11- Keys <br /> (( / _ �( 7 Preservation Key: Container Information Key: <br /> S L-u �.Ati1 �� )1 lV �V _ L FIIte`ed Imo) '� A. H SO, 7. 40 ml Vial <br /> Address Fa= rofConlatrrcro B. HCL 2. 1 LAmber <br /> /cJIfi /fie r' C/`� — C��% Cenwiner , C. Na0HNO, - 3. 250 ml Plastic <br /> ! 47 im.rmauon y D. None 4. Enc r Plas-lic <br /> ccity state zip E-magi Address E. None 5. Encore <br /> m PARAMETER ANALYSIS 8r METHOD F. Other: 6. 2oz.Glass <br /> G.Other: 7. 4 oz.Glass <br /> .�V i �-�' 1S�OG� s[:++(F.hncll 4�r '1 u�• "a� 8. 8oz-Glass <br /> Project Name/Loca6on(City,State)y� Project p: / j i H. Other: 9. Other: <br /> 6 L_L 110.Other: <br /> Sampler's Pnnt Name: �('� Sampler's Signature -Matrix Key: <br /> ` � SO-Soil SE-Sediment NL-NAPL/Od <br /> -' W-Wacer SL-Sludge SW-Sample Wipe <br /> T-Tissue A-Air Other: <br /> Sample ID correction Type(✓) Matrix <br /> Date Time comp Grab ///REMARKS <br /> b/ w- o`1- o l-TVA 9 34itl WAS ✓ tE 15V C-t <br /> i <br /> Special Instructions/Comments: ❑Special QA/QC Instructions(-'): <br /> Laboratory Information and Receipt Relinquished By Received By Relinquished By Laboratory Received By <br /> Lab Name I Cooler Custody Seal(-1) Printed Name: /2 Printed Name: Pnnted Name Printed Name. <br /> CYIA- <br /> Cooler packed with ice(✓) ❑ Intact ❑ Not Intact Signature Signature: Signature. Signature: <br /> Specity Teryaro�,na Requirements: Sample Receipt: Farm Firm/Couner Firm/Courier Firm <br /> �P-g <br /> Tracking n: Condition/Cooler Temp:0C Date/T Dat e: Daterrime: DateRme. <br /> D3S20 �J q 7v/i1 / 30 � a l y /?)D /6 3 /0:9S- <br /> 20130826 <br /> 730826 CofCAR Form 01.112.2007 Distribution: WHITE—Laboratory returns with results YELLOW—Lab copy PINK—Retained by ARCADIS <br />