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Rev.1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> Fm(Ofl 91 928-3300 FAX 916)928-3341 Lab: <br /> Project Name: Anal sis Re nested <br /> Project Number: <br /> Project Manager: c <br /> Company: EMCON f° <br /> Address: 1433 North Market Boulevard o <br /> U <br /> Sacramento,CA 95834 6 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 <br /> Sampler's Signatu <br /> z REMARKS <br /> Sample LAB Sample "s: Container T es <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 REQUIREMENTS <br /> REIR <br /> QUEMENTS X I. Routine Report <br /> Signature Signature Signature Signature 241v 4a hr_ s dny 1I. Report(includes DUP,MS <br /> X Stmd.d(-to-ts.corking dnys) MSD,as required,may be <br /> Printed NamePrinted Name Printed Name Printed Name —p—lid.Vorbol R—dl, charged as samples) <br /> Protide FAX Prdi hwy Results 111.Data Validation Report <br /> Firm Firm Firm Firm Requested Repon Dino: (includes All Raw Data) <br /> Date/Time Date/Time Date/Time Date/Time RWQCH <br /> Ls/P Ls/TRACEN <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 /> Firm Firm500 <br /> liter glass: 6 <br /> Date/Time Date/Time 2x6 s/s ring: 7lass'ar, 8 <br /> CN FIGURE <br /> WATER SAMPLE FIELD DATA SHEET -3 <br />