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Rev. 1199 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> HKOII 91 92&3300 FAX 91 928-3341 Lab: <br /> Project Name: <br /> Project Number: Anal sis Re uested <br /> Project Manager: ani <br /> Company: EMCON m <br /> Address: 1433 North Market Boulevard o <br /> Sacramento,CA 95834 U <br /> Phone: (916)928-3300 0 <br /> FAX: (916)928-3341 <br /> Sampler's Signat.... E <br /> Sample LAB Sample REMARKS <br /> I.D. Date Time I.D. Matrix Container Tynes <br /> 0 Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINTQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS <br /> Signature Signature Signature X I• Routine Report <br /> gn Signature 24 hr 4s hr 5 day II. Report(includes DUP,MS <br /> X Sw-dard(-10.15 7king days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name <br /> Provide Verbal Preliminary Results charged as samples) <br /> Firm Firm Prmide FAX Preliminary Results <br /> Firm Firm III.Data Validation Report <br /> Requeaed Report Dare: (includes All Raw Data) <br /> DatelTime Date/TimeRWQCB <br /> Date/Time Date/Time <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: MDLs/PQLs/1RACE# <br /> Container Types Key: <br /> Signature Signature 40 ml VOA: I <br /> 250 ml LPE: 2 <br /> Printed Name Printed Name 500 nil LPE: 3 <br /> 1 liter HDPE: 4 <br /> Firm TD <br /> nn 500 ml glans: 5 <br /> 1 liter glass: 6 <br /> Date/Time atelTime 2x6 s/s ring: 7 <br /> lass jar:Ail 1% g <br /> FIGURE <br /> EMCON WATER SAMPLE FIELD DATA SHEET ®3 <br />