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M no we M tin ow so am dw w <br />Rev. 1 /99 <br />It 1 CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br />1433 North Market Boulevard, Sacramento, CA 95834 r, . <br />aunun 9E) 928-3300 FAX 916 928-3341 <br />Project Name: <br />Lab: <br />Project Number: <br />An <br />sis Re uested <br />� <br />Project Manager: <br />Company: EMCON <br />Ig <br />Address: 1433 North Market Boulevard <br />0 <br />Sacramento, CA 95834 <br />U <br />Phone: (916) 928-3300 <br />0 <br />FAX: (916) 928-3341 <br />E <br />Sampler's Signatul <br />Z <br />Sample LAB <br />~r•=: <br />REMARKS <br />!Sa:mple <br />I.D. Date Time I.D. fix <br />,`$'`' <br />ContainerT es <br />0 <br />Preseryations <br />0 <br />010 <br />T[ <br />0 <br />0 <br />I I --I --I -T--I- <br />I I I <br />RELINQUISHED BY <br />RECEIVED BY <br />RELINQUISHED BY RECEIVED BY <br />TURNAROUND <br />REPORT REQUIREMENTS <br />Signature Signature <br />REQUIREMENTS <br />241u <br />X I. Routine Report <br />Signature <br />Signature <br />4s hr s dap <br />11. Report (includes DUP, MS <br />Printed Name Printed Name <br />X Stamlard (-1a-13 wo,king days) <br />MSD, as required, may be <br />Printed Name <br />Printed Name <br />P-4& Verbal Prdiimi—y R -1t, <br />charged as samples) <br />Firm <br />Pwide FAX Prdiminary R,sWu <br />III, Data Validation Report <br />Firm <br />Firm <br />Firm <br />Date/Time Date/Tima <br />Rdq.wcd Rdpw Datd: <br />(includes All Raw Data) <br />RWQCB <br />(NDLs/P Ls/TRACE# <br />DatRELI <br />DatelTime <br />RELINQUISHED By <br />RECEIVED BY <br />Speciallnstrvetions/Comments: <br />Container Types Key: <br />40 ml VOA: 1250 <br />Signature <br />Signature <br />ml LPE: 2 <br />500 ml LPE: 31 <br />Printed Name <br />Printed Name <br />liter HDPE: 4 <br />500 <br />500 ml glass: 5 <br />Firm <br />Firm <br />liter glass: 6 <br />2x6 s/s ring: 7lass <br />Date/Time <br />Date/Time <br />jar: 8 <br />EMCOJ <br />WATER SAMPLE FIELD DATA SHEET <br />FIGURE <br />,A-3 <br />