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Rev. 1/99 <br /> A*Z* CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> U1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> EIMOtI 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Requested <br /> Project Number: to <br /> Project Manager: <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard 0 <br /> U <br /> Sacramento,CA 95834 6 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 E <br /> z <br /> Sampler's Signatu REMARKS <br /> Sample LAB Sample Container Types <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 /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 24 hr 48 hr 5 da) II. Report(includes DUP,MS <br /> Y Standard(-10-15 uorking days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal PreliminaryResults charged as samples) <br /> Protide FAX Preliminary Results III.Data Validation Report <br /> Firm Firm Firm Firm Requested Report Date (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time (MDLs/PQLs/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 /> 500 ml LPE: 3 <br /> Printed Name Printed Name 1 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/Time lass jar: 8 <br /> FIGURE <br /> L WATER SAMPLE FIELD DATA SHEET ®3 <br />