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<br />IFV116 <br />ITiVIRONPIENTAI: _ <br /> <br />www.fglinc.corn CHAIN OF CUSTODY <br /> <br />AND ANALYSIS REQUEST DOCUMENT <br /> <br />:111,11ylicsd <br /> <br />Client: Michele Jacobs <br />Customer Number: 3019285 <br />Address: 19818 N. Ripon Rd <br />Ripon, CA 95366 <br />Phone: (209)481-7555 Fax: <br />Email Address: michelejj928@gmail.com <br />Contact Person: Michele Jacobsc, <br />Project Name: (ct5is, N. 44_,; g-ct <br />Purchase Order Number: <br />Quote Number: <br />! . Lab Number: <br />a.g/068 <br />TEST DESCRIPTION AND ANALYSES REQUESTED Method of Samplingc Campos& (C) Grab ((3) e <br />i <br />til <br />1 z Type of Containeta: (0)Glass (P)PiaatIc (V)V0A (MT)Metel Tube Potable (P) Non-Potabis (NP) A9 Water (ABM if <br />gE <br />§ <br />II <br />R [ a <br />111- <br />Et <br />st, <br />! <br />- : .. <br />a <br />.°2- Beet (Sys) System (MC) &WOO (W) Waste Beet (ROLIT)RoutIne (RPT)Repeat (0714)0ther (RPL)Replace I <br />1 <br />f, <br />2 <br />k <br />F <br />P Pressrvatvez (1) WON ZnAo, (2) Ne0H, (3) HCI (4) H2SO4, (5) F0103, (6) Na25203, (7) Other Qrfoo I <br /> <br />z <br />% <br />'I o <br />Z. <br />Rush Analysis: 5 Day 4 Day []3 Day 2 Day 24 hour <br />Rush pre-approval by lab (initals): <br />Electronic Data Transfer: Na State Client Other: <br />Sampler(s): <br />Aklit,tab,3 <br />Sampling Fee: Pickup Fee: <br />Compositor Setup Date: Time: <br />Samp <br />N I <br />Location Description Date <br />Sampled <br />Time <br />Sampled <br />/ kik'ben 7Z t(41--a' ez.2Aa2 /too <br />Remarks Relinquis 4 Time: <br />44/4a1.5 /100 <br /> <br />' uished te: Time: <br /> <br />/ /2,0g75 17e- <br />Relinquished Date: Time: <br />-,--)- /0/7 <br />pate: The: Received By: pate: Time: <br />.4;v2),R5 /iaji4s hi /a,,v5 /71)0 <br />Received By: Date: Time: <br />11/1"( i/1-3/1- 1d/3 <br />Corporate Offices & Laboratory <br />853 Corporation Street <br />Santa Paula, CA 93050 <br />TEL: (805)392-2000 <br />CA ELAP Certification No. 1573 <br />Office & Laboratory <br />2500 Stagecoach Road <br />Stockton, CA 95215 <br />TEL: (209)942-0162 <br />CA ELAP Certification No, 1563 <br />Office & Laboratory <br />563 E, Undo Avenue <br />Chico, CA 95925 <br />TEL: (530)343-5818 <br />CA ELAP Certification No. 2870 <br />Office & Laboratory <br />3442 Empresa Drive, Suite D <br />San Luis Obispo, CA 93.401 <br />TEL: (805)783-2940 <br />CA ELAP Certification No. 2775 <br />Office & Laboratory <br />9411W. Goshen Avenue <br />Visalia, CA 93291 <br />TEL: (559)734-9473 <br />CA ELAP Certification No. 2810