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Rev. 1/99 <br /> CHAIN OF CUSTODY/ LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> IEIII(OA 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Anal sis Requested <br /> Project Number: 12 <br /> Project Manager: c <br /> Company: EMCON E <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 E <br /> Sam ler's Si atur . z' REMARKS <br /> Sample LAB Sample Container Types <br /> I.D. Date Time I.D. Matrix Preservations <br /> 01 1 <br /> 01 1 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1. Routine Report <br /> Signuture Signature Signature Signature 24 hr 48 hr 5 day 11. Report(includes DUP,MS <br /> s�w�auad t-lass wwkins duy9) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Provide FAX Preliminary Results 111.Data Validation Report <br /> First Firm firm Firm Requesled Ronal Dare: (includes All Raw Data) <br /> —R B <br /> Date/time Date/rime Date/time JDatefrime (MDLs/PQLs/rRACE# <br /> RELINQUISHED BY r ' RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> 40 ml VOA: 1 <br /> Signature Signature 250 mi LPE: 2 <br /> 500 ml LPE: 3 <br /> Printed Name Printed Name I liter IIDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm 1 liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/rime I glassjar: 8 <br /> FIGURE <br /> EMCON 00 <br /> CHAIN OF CUSTODY DOCUMENTATION ®3 <br /> r <br />