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2aceAnalyfical <br />CHAIN -OF- CUSTODY I Analytical Request Document <br />The Chain -of- Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. <br />Section A Section B Section C <br />Page: of <br />Required Client Information: Required Project Information: Invoice Information: <br />Company. PAS �� L „Vl Repor, To: Attentxm: TD 1. <br />F� �VtM¢h+o,1 �'01�� D,aff_S U Y\ pro, <br />1695665 <br />Address: H r, n C y.. , � S fi' <br />Copy To: <br />Company Name: ?a`mt IR�Vi � NQN,&I <br />REGULATORY AGENCY <br />D^ vwey -' CGa 9011 � <br />O <br />Adtlress:) 1q n C r sir, <br />l "I�J V <br />j NPDES I— GROUNDWATER ( DRINKING WATER <br />i— UST RCRA ( OTHER <br />Email To: , 1 <br />(Aw Gt fVl —QNVIr'Q�QI�1 ' <br />Punchase Order No.: <br />Pace Quote <br />Reference: <br />`, <br />F 3,) =1 <br />Project Name: /� ��� j l <br />�'0. <br />Project <br />Site Location <br />$63- -811 <br />-S3L(- Ju"f <br />l,.p iJi D ,iT1,hQ. <br />Mace <br />g <br />STATE: <br />Requested Due Date/TAT: <br />Project Number: <br />Pace Profile #: <br />Requested <br />Analysis <br />Filtered <br />(YIN) <br />Section D Matrix Codes <br />= <br />Required Client lnformadon MATRIX f CODE <br />m <br />COLLECTED <br />Preservatives <br />} <br />Drinking Water DW <br />Water WT <br />c <br />m <br />0 <br />O <br />y <br />Waste Water WW <br />Product P <br />'S <br />m <br />COMPOSITE <br />START <br />COMPOSITE <br />ENDlGIiAa <br />J <br />= <br />Z <br />� 0 4; <br />���!!! <br />Soil/Solid SL <br />0 <br />JO <br />y <br />O <br />y <br />SAMPLE ID Oil OL <br />11 <br />U <br />a <br />CC <br />W <br />.� <br />m <br />w <br />> <br />v <br />Wipe WP <br />(A -Z, 0 -9 1,-) Air AR <br />O <br />n. <br />F— <br />Sample IDS MUST BE UNIQUE Tissue TS <br />o <br />w <br />w <br />m <br />N <br />U <br /># <br />Other OT <br />X <br />a <br />J <br />a <br />OZ <br />(D <br />m <br />O <br />2 <br />6 <br />L <br />T <br />to <br />.1 <br />w <br />a <br />Q <br />¢ <br />0 <br />c <br />z <br />U <br />Om <br />to <br />a� <br />L <br />Q <br />t J <br />V <br />aai <br />rn <br />DATE <br />TIME <br />DATE <br />TIME <br /># <br />_ <br />= <br />S <br />Z <br />Z <br />2 <br />O <br />.r► <br />t7o <br />t7i0 <br />}� <br />Pace Project No./ Lab I.D. <br />1 <br />Sep -vlC.e A�r-e o. Sam <br />L <br />C71 <br />I <br />311-11133D <br />2 <br />X <br />X <br />rw <br />2 <br />Service. Areo, N a r'4 <br />I S 3 5 <br />3 <br />E64 }- S ide Wa 11 <br />L <br />15 4 o <br />3 <br />4 <br />N IW ^ -rJ%� wkkk <br />I S`1 S <br />—01 <br />s <br />1 we, <br />IS.St <br />6 <br />Sr'%4'^ S;at.w k <br />tS55 <br />t G <br />7 <br />Soil P; ll- B { hV-'\ <br />1 <br />1600 <br />a <br />CXL-O'Vx " &I Nq- EODZc - <br />162-0 <br />R'g <br />9 <br />E1cc o.YAF S „1 P lc Wes }- <br />1636 <br />11 <br />12 <br />ADDITIONAL COMMENTS <br />RELINQUISHED BY I AFFILIATION <br />DATE <br />TIME <br />ACCEPTED BY/ AFFILIATION <br />DATE <br />TIME <br />SAMPLE CONDrrIONS <br />Tae► Ta Falme,f to <br />3 (z$ <br />1500 <br />1 Ciro <br />A <br />SAMPLER NAME AND SIGNATURE <br />o <br />m <br />OD <br />o <br />C R!GINAL <br />.n <br />E <br />a 2- <br />> <br />'-80— <br />, ? <br />m> <br />c <br />d z <br />> <br />PRINT Name of SAMPLER: <br />�e13ok'Z.S <br />SIGNATURE of SAMPLER: <br />Signed 2 �� p' ` ' <br />4�j "� <br />F, <br />O <br />v: <br />M <br />` <br />MM/DDNY): <br />co <br />'important Note: By signing this form you are accepting Pace's NET 30 day payment terms and agreeing to late Charges of 1,5% per month for a(iy Jmt ice5%ot paid within 30 days F- ALL- 0- 020rev.07, 15- May -2007 <br />