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0 0 Rev. /99 <br /> / CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> `J 1433 North Market Boulevard,Sacramento,CA 95834 P.O„ <br /> mcon 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Requested <br /> Project Number: N <br /> Project Manager: c <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard 0 <br /> U <br /> Sacramento,CA 95834 6 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 <br /> Sampler's Signatu Z REMARKS <br /> Sample LAB Sample container T pes <br /> I.D. Date Time 1.D. Matrix Preservations <br /> 0' <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 241,r 48 hr_ 5 day II. Report(includes DUP,MS <br /> X Standard(-10-15 working days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Protide FAX Preliminary Results III.Data Validation Report <br /> Firm Firm Firm Firm Requested Report Dare: (includes All Raw Data) <br /> R W QCB <br /> Date/Time Date/Time Date Time Date/Time (MDLs/PQLs/TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> 40 ml VOA: 1 <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LPE: 3 <br /> Printed Name Printed Name 1 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/Time =lass jar: 8 <br /> FIGURE <br /> WATER SAMPLE FIELD DATA SHEET <br />