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MMWMMMMWMMMMW " mom ■! as m <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM Page_of_ <br /> Shaw Environmental s PO Number: Direct Bill to San Joaquin County <br /> 1326 North Market Boulevard Sacramento CA 958340 �r�, Lab: CAS,Simi Valley <br /> Project Name: Harney Lane Landfill,San Joaquin County Analysis Requested. <br /> Project Number: 124593(Ground Water) <br /> Report to: Sheila Richgels <br /> <sheila.richgels@shawgrp.conu <br /> Company- Shaw Environmental <br /> Address: 1326 North Market Boulevard O <br /> U cv <br /> Sacramento, CA 95834 0 <br /> Dir Pb: (916)565-4327 / FZJ (916)56--y4356 <br /> Sampler's Signature: z W U REMARKS <br /> Sample LAB Sample 1 125tnt Container Types <br /> I.D. Date Time I.D. Matrix Sect NP NP Preservations <br /> MW-1 iall water 5 3 1 1 <br /> MW-2 water 5 3 1 1 <br /> MW-3water 5 3 1 1 <br /> MW-4 water 5 3 1 1 <br /> ield Blank water 2 2 <br /> f ri Blank Qii+ water 2 2 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECVIVED 11Y TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Si re Signature Signature Signature '• 24br 48 br 5 day II. Report(includes DUP,MS <br /> LorAG X Staudud(-10.15 working days) MSD,as required,may be <br /> Pri t Name Printed Name Printed Name Printed Name Provide <br /> Provide VerbalPrelirainaryResults charged as samples) <br /> 1_�/�/ &5 <br /> —_ttovldoPAxPral7minaryResults III.Data Validation Report <br /> Firs#t1so Ea Firm Firm NDrt!,/Tm, <br /> Requested ReportDate: (includes All Raw Data) <br /> , E_(MDI^s/PQLs/TRACE#)RWQCB . <br /> Date/Time y Z'1.� Date/Time Date/Time <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> Columbia Analytical 40 ml VOA: 1 <br /> Signature Signature Please report MDLs,PQLs,and Trace. 2655 Park Center.Drive,Suite A 250 ml LPE: 2 <br /> Simi Valley,Calif 93065 500 ml LPE: 3 <br /> Printed Name Printed Name 805-526-1161/lit: 805-526-7270 1 liter HDPE: 4 <br /> Contact: Karen Ryan 500 ml glass: 5 <br /> Firth Firm 1 liter glass: 6 <br /> EDDs to<susan.watermanC�shawgrp.conv Ship UPS Acct 9653E1 2x6 s/s ring: 7 <br /> Date/Time jDatwTime gids.: g <br />