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Rev. 1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> ,Dz 1433 North Market Boulevard,Sacramento,CA 95834 P'0.: <br /> FT(Ofl 91 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Anal sis Re nested <br /> Project Number: N <br /> Project Manager: c <br /> Company: EMCON 'ro <br /> Address: 1433 North Market Boulevard <br /> 0 <br /> U <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 <br /> Sampler's Signatul <br /> z REMARKS <br /> Sample LAB Sample `aE' ContainerT es <br /> I.D. Date Time I.D. Matrix Preservations <br /> 0 <br /> **1 1 1 -- <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISIMED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I• Routine Report <br /> Signature Signature Signature Signature 241. 48 hr s dry II. Report(includes DUP,MS <br /> X srrndord(-laaa corking drys) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Pr4roinory Rcanlrs charged as samples) <br /> Provide FAX I'Mirrinrry Rcauhs 11I.Data Validation Report <br /> Firm Firm Firm Firm Requested Repon Dore: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time (IvIDLs/P Ls/TRACE# <br /> RELINQUISEEDBY RECEIVED BY Speciallnstructions/Comments: Container Types Key: <br /> Signature Signature 40 ml VOA: 1250 ml LPE: 2 <br /> 500 ml LPE: 3 <br /> Printed Name Printed Name 1 liter I-IDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm 1 liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/Timc lass jar. 8 <br /> FIGURE <br /> EMCON WATER SAMPLE FIELD DATA SHEET A,-3 <br />