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® 9 099 <br /> FeCHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> 9MCO(I 91 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Requested <br /> Project Number: <br /> La <br /> Project Manager: m <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard 0 <br /> U <br /> Sacramento,CA 95834 6 <br /> Phone: (916)928-3300 m` <br /> FAX: (916)928-3341 <br /> E <br /> Sampler's Signatu . z REMARKS <br /> Sample LAB Sampler:::>''' Container Types <br /> I.D. Date Time I.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 RE,QUHtEMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 241r 48 hr 5 day II. Report(includes DUP,MS <br /> X Standard(-10-15 corking days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preliminary Rosults charged as samples) <br /> Provide FAXPreliminary Rasnhs III.Data Validation Report <br /> Finn Firm Firm Firm Requested Report Date: (includes All Raw Data) <br /> Date/Time Date/Time Date/Time Date/Time RWQCBLS/P Ls/TRACE# <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> Signature Signature 40 ml VOA: 1250 ml LPE: 2 <br /> Printed Name Printed Name 500 ml LPE: 31 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Flan Firm500 <br /> liter glass: 6 <br /> Date/Time D2x6 s/s ring: 7ate/Time lass'ar: 8 <br /> FIGURE <br /> EMCON WATER SAMPLE FIELD DATA SHEET -3 <br />