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CFrAIIFCUSTODT[ABTRATORY ANALYSIS R�*RTRM FO <br /> iyt:Col <br /> SerVlces'"L 3334 Victor Court•Santa Clara,CA 95054 r <br /> ^^£« ny (408)74T8-9700•FAX(408)74B-9860 SERVICE REQUEST NO_, aQ (9© q ftp P O#YM4(7 PAGE OF Z. <br /> PROJECT NAME mC f{{C�frL J 60-Z flg S0 ANALYSIS REQUESTED <br /> PROJECT A� ` IA&V 1.+ PRESERVATIVE HCI HCl HCI NP NP NP NCI HN2 NP H S0, NdOH <br /> �� ' v S Cz U) o � p p �� <br /> COMPANY S 15vi tj f rp-mzot-)-. w Z—f ��L� '`O <br /> fix0 CO CD caf <br /> ADDRESS 2 CPZ. --U, �✓' q Y �Q'D "y o <br /> UR <br /> kop {ix ►i �z. �Sb Iz- PHONE fi ° � � p 4 <br /> iL <br /> ,L 2 �z o C" <br /> FAX O (`a aro a m !P c a� y > y U O p 4 <br /> SAMPLER'S SIGNATURE O�v m Q (5OOm a �� �;y v m =Q a O <br /> co mro co �y yp =�+ 75m y� o UO <br /> SAMPLE LAB SAMPLE a d o2Z 2ZV y y" arc rozv <br /> ID DATE TIME ID MATRIX Z ,cn r�� ti� �? ¢>`0ro a�Q�y ��p ��° aQ 2= U� p REMARKS 4th" � c � <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> Signature Si ren Signature Signature — t day _2 day_3 day — - 1 Routine Report <br /> �;�!�y r(� — II Report(includes M5 <br /> Printed Name Printed Name Printed Name Printed Name —5 day `Other MSD,as required,may be <br /> charged as samples) <br /> Firm Farm � Firm Firm � Standard�,Wd,, III Data Vafidahon Report <br /> (includes ati Raw Dara) <br /> .O0 Results Due _ MDLs/PQLs/Trace# <br /> Date/Trme Date/7ime Date/Time Date/Trme <br /> a I if-10 u - Electronic Data Deliverables <br /> RELINQUISHED BY RECEIVED BY SAMPLE RECEIPT Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS K <br /> Signature Signature Ci le which metas are o be analy– <br /> zed <br /> Printed Name Printed Name Metals Al Sb Ba Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sri V Zn <br /> Fxm Farm <br /> As Pb Se TI Hg DatelTime DatelTime Y UP <br /> 3 2— <br /> Shipped <br /> — <br /> Shi ed Viaffrackin2# Storage <br /> Will sample results be used in connection with drinking water regulations? ❑ Yes ❑ No If yes,you must so indicate by writing DW' for each such sample <br />