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Chain of Custody and Analytical Request Record <br />PLEASE PRINT (Provide as much information as aossible.) <br />Page I of J- <br />py Nye <br />Project Name, PWS, Permit, Etc. <br />Sample Origin <br />EPA/State Compliance: <br />e, r ve� s <br />U)h ,() <br />State: � <br />Yes [I No ❑ <br />3eport Mat Address (Required): a�5 un.p 3�vc� <br />Contact Name: Phone/Fax: <br />Cell: <br />Sampler. (Please Print) <br />Invoice Oontact & Phone: <br />Purchase Order: <br />Quote /Bottle Order: <br />No Hard Copy Email , (�i Qne� �S. otn <br />—5, l C. <br />�(05� <br />nvoice Address (Required): 5 ti'3`I, Jr��� <br />Contact ELI prior to <br />RUSH sample submittal <br />,LA C v �Z <br />10 ,� <br />p <br />R <br />for charges and <br />scheduling - See <br />> No Hard Copy Email: <br />> ° '' m <br />� s =� <br />oa _Ml c <br />W <br />U <br />Q <br />o <br />i U <br />I <br />Inst ruction Page <br />F-7-o <br />Comments: <br />S R <br />ecial ort/Formats: <br />P eP <br />C , <br />DW ❑ EDD /EDT(Electronic Data) <br />62 cd <br />n � m , <br />�' <br />Q <br />oe too: O <br />❑ POTWNVWTP Format: <br />z QQI o <br />E <br />w <br />S <br />Cmtodysemi <br />❑ State: ❑ LEVEL IV <br />>I <br />w <br />W <br />on eume Y <br />❑ Other: ❑ NE LAC <br />{{ <br />M <br />on Cooler N <br />(n <br />H <br />intact N <br />SAMPLE IDENTIFICATION <br />Collection <br />Collection <br />MATRIX <br />SiSignature N <br />(Name, Location, Interval, etc. ) <br />Date <br />Time <br />Match <br />9 { •� <br />co l�'ti <br />IZ p <br />LU <br />f <br />2• lit <br />1236 <br />„J <br />(a t�, i4 <br />15c <br />Co- l •) <br />ZZ} <br />o <br />t <br />4 <br />i <br />0 <br />� <br />0 <br />V <br />t✓ustbdy (/// ggg���'r1 {n1gtdshed`byy(print)�: .`` at l(��me(: ry '. ` Recdvedby(prvAl DaWl -trite: Sigratwe <br />t�ecora I ReI nqu Ahed by (print): Datenime: Signature: Received by (Prot, OaterTwm: Signature <br />A U ST bell -- - -- Tl..,- �_Z-- . --Il,_ —!!-� ••�•- <br />al: Return to Client: Lab Disposal: )L <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis requested. <br />This serves as notice of this possibility. All sub - contract data will be clearly notated on your analytical report. <br />Visit our web site at www.enerovlab.com for additional information, downloadable fee schedule, forms, and links. <br />