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Z ARCADIS <br /> CHAIN OF CUSTODY & LABORATORY Lab Work Order# • <br /> lnSasrruoure.environment.buddngs �,4,,,G1r f ANALYSIS REQUEST FORM Page I of <br /> cornnd a Corrprrny Name: /` 7 lnpnonn: preeervWve �` L Key$ <br /> � 1/,5��o `IAZY /j,1,,, ✓4 S./p- fled. y Prpsrvatlon Kay: ContalnarlMamatlon Key: <br /> f_ t r!e "1-�l 5"16- y�sy t 1 A. H,SO, 1. 40 ml vial <br /> Address: Fax B. HCL Z t LAmber <br /> 7 Z a of Cgnralnen I ' C.HNO 3. 250 ml Plasdc <br /> td <br /> o•C ZG'LU w6/1 f r 2- 3 D.NaOH 4. 500 ml Pit, <br /> NaOH <br /> E. None 5. Encons <br /> city s"° zip E-m"''""`""' PARAMETER ANALYSIS&METHOD F. Other. 6. 2tu,Glass <br /> h I T. 4 ox.Glass <br /> & <br /> r�ysary'fIlC/a 9ybo8 ./rfAlrtA'�i/�wwlcv idre.rl��1`uSEO"`'t G.other. g. ao:.Glass <br /> Project NamMLotrli (Cil,Sts10}: Project r (J H.Other 9. Other, <br /> 0 4 f_ (0'4 LIP fi oo)`IS'Ya. oo a/ r+�� \ � 10.Other <br /> Sampler's Printed Name' �h/ Snmplor's Sig \' Matrix Key: <br /> /`1.Y21, so-Soil SE-Sediment NL-NAPLfOil <br /> \ \ T•Tissue AMter SL <br /> - Sludge 5WI-Sample Wipe <br /> Sample ID collection Type V) Matrix ��� v 2 <br /> Date Time Comp Grab 4 v //REMARKS <br /> /06-d-1 Ono 7 / Ay fii4 <br /> Special InstructlonsdComments: ❑Special QAIQC Instructions(✓): <br /> hA� tplh01� <br /> Laborstary,informatkm and Receipt Relinquished By Received By Relinquished By Laboratory Received By <br /> Lab Name' Cooler Custody Seal(✓) Printed Name' Printed N mo. � I Printed Name, Printed Na <br /> ..�C -Agl7l L�6 7o-,,i, f2ozf, EIS <br /> E?cooler packed with ice(✓) ❑ Intact ❑ Not Intact S-gnamta � Sign, r - Si9nnwrn: S <br /> Splmity Tumamund Rrxlurtomonls: Sample Receipt Firm <br /> t4m4-zf Ia <br /> SHppnq TracMinq e: Condition/Cooler Temp: G Dale.Timo: DaleMmo. Daur'Timo DatcJTimo: <br /> j A- /o�i r !! D j�J p to.Z".f/ <br /> 20730526 core AR Form 0+.12.2007 Distribution: WHITE-Laboratory returns with results YELLOW-Lab copy PINK-Retained by ARCADIS <br />