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r rs rr rr r r rr rr rr ® r rr r tr rr w r rr r <br /> Rev.1/99 <br /> r+�1 CHAIN OF CUSTODY/LABORATORY•ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 <br /> Emcon 91 928-3300 FAX 916 928-3341 P.O.: <br /> Project Name: Lab: <br /> Project Number: Anal sisRequested <br /> ProjectManager: l2 <br /> Company: 1 MCON <br /> Address: 1433 North Market Boulevard v <br /> Sacramento,CA 95334 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 a <br /> Sampler's Signatu <br /> Sample Z <br /> p LAB Sample yy+ REMARKS <br /> 1.D. Date Time 1.D. Matrix ? coniainerT es <br /> pPreservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND <br /> REPORT REQUIREMENTS <br /> Signature Signature Signature REQUIREMENTS X I. Routine Report <br /> Signature Signature 241v 49hr 56y U. Report(includes DUP,MS <br /> Printed Name Printed Name Printed Name X smada-d(-ro-15 no l;ias d.ys) MSD,as required,may he <br /> Printed Name Provide Vehol Prdiminnq Amalt% charged as samples) <br /> FirmProvide FAXPrclWi,my FL..iu <br /> Fimt Firm Firm III.Data Validation Report <br /> aequeztea aepnn Date: (includes All Raw Data) <br /> Date/Time Date/Time Datc(TfineRWQCB <br /> RELDNQUISM,DBY RECEIVED BY Special Instructions/CommentsDate/Tinte ./P LsrrRACEN <br /> Container Types Key: <br /> Signature Signature 40 ml VOA: 1 <br /> 250 ml LPE: 2 <br /> Printed Name Printed Name 500 ml LPE; 3 <br /> 1 liter HDPE: 4 <br /> Firm Fimt 500 ml glass: 5 <br /> 1 liter glass: 6 <br /> Dale/Time Dahl= 2x6 s/s ring: y <br /> lass'ar: 8 <br /> C ,P-q, <br /> FIGURE <br /> WATER SAMPLE FIELD DATA SHEET -3 <br />