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MM MM M IMM M M MM <br /> 199 <br /> 00 CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> >tI1t00 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Requested <br /> Project Number: N <br /> Project Manager: <br /> Company: EMCON <br /> c <br /> Address: 1433 North Market Boulevard 0 <br /> U <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 m <br /> FAX: (916)928-3341 <br /> E <br /> Sampler's Signature. z REMARKS <br /> Sample LAB Sample <br /> Container T es <br /> I.D. Date Time I.D. Matrix E Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BYRECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 20-nr as hr s am 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 /> Provide FAX Preliminary Results III.Data Validation Report <br /> Firm Firm Firm Firm Requested Report nate: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time MDLs/P Ls/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 /> Printed Name Printed Name 500 mlLPE: 31 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm 1 liter glass: 6 <br /> Date/Time Date/Time 2x6 s/s ring: 7lass jar: 8 <br /> FIGURE <br /> WATER SAMPLE FIELD DATA SHEET ®3 <br />