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M M M M M M M M M M M M M ® M M <br />CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM Page _ of _ <br />IT / EMCON - 1433 North Market Boulevard, Sacramento, CA 95834 Service Request No: IT P.O. No: <br />(9161928-33[111 FAX (91619?.R.33d1 r .,r.• Q A-. <br />Project Name: Foothill Landrill, San Joaquin County <br />----- - <br />Anal sis Requested <br />-- ------------- ------ <br />Project Number: IT# 791289 / 16037-200.000 <br />:o <br />Project Manager: Steve Giacomini <br />Company: IT/ EMCON <br />s <br />a <br />Address: 1433 North Market Boulevard <br />0 <br />N <br />rn <br />? <br />Sacramento, CA 95834 <br />0 <br />Q <br />Phone: (916) 928-3300 <br />o <br />w <br />o <br />FAX: (916) 928-334�1 <br />u <br />U <br />Sampler's Signature: - ✓'h �- <br />�' <br />,o <br />U <br />l" <br />Z <br />O <br />Ca <br />I <br />IREMARKS <br />Sample LAB <br />Sample <br />1 <br />1 <br />4I <br />JContainerTypes <br />I.D. Date Time I.D. <br />Matrix <br />I <br />HCIJ <br />NP <br />Preservations <br />MW -I {(GU <br />water <br />4 <br />3 <br />1 <br />MW -2 au t31 <br />water <br />4 <br />3 <br />1 <br />MW -3 <br />water <br />4 <br />3. <br />1 <br />=' <br />RELINQUISHED BY <br />RE I BY <br />INQUISHED BY <br />............. <br />RECEIVED BY <br />TURNAROUND <br />REPORT REQUIREMENTS <br />w� <br />REQUIREMENTS <br />24 hr 48 hr 5 Jay <br />X 1. Routine Report <br />11. Report (includes DUP, MS <br />Signature1g <br />l• <br />re Signature <br />�L <br />Signature <br />C. `vY� n �'� <br />X Siandard (-10-15 working days) <br />Provide venal Prelaninar) Results <br />MSD, as required, may be <br />charged as samples) <br />Printed Name <br />Pri d Name Printed Name <br />Printed Name <br />(''- ,-" c .+: •" <br />Provide FAX Prelinunary Rcudls <br />Requested RgxnI Dane: <br />III. Data Validation Report <br />(includes All Raw Data) <br />Firm / <br />j <br />Firm Firm <br />Firm <br />1p USS <br />X RwQCIs <br />(HDLs/PQLsrrRACE#) <br />Date/Time <br />Datifrime Dale/Time <br />Daterl ime <br />RELINQUISHED BY <br />RECEIVED BY <br />Special Inslructions/Comments: <br />Container Types Key: <br />Signature <br />Please report MDIs, <br />PQIs and'Frace. -if LU atr(.),t <br />Sequoia Analytical <br />6:O C.r- C 13) 819 Striker Avenue, Ste. 8 <br />40 ml VOA: <br />250 nil LPE: <br />I <br />2 <br />Signature <br />_ <br />Printed Name <br />Nitrate -Nitrogen <br />has <br />a 48 -hr <br />hold time. <br />Sacramento, Ca 95834 <br />916-921-9600 <br />500 nil LPE: <br />I liter IlDPE: <br />3 <br />4 <br />Printed Name <br />Firm <br />500 n11 glass: <br />I liter glass: <br />5 <br />6 <br />Firm <br />jDalefrinle <br />30 s/s ring: <br />-_glass iar:_ -- _- <br />7 <br />8 <br />I)altCjime <br />