Laserfiche WebLink
Chain of Custody and Analytical Request Record Page of <br /> PLEASE PRINT Provide as much information as ipossible. <br /> Company Name: Project Name, PWS, permit, Etc. Sample Origin EPA/State Compliance. <br /> Sa,Hft: Zo+6 <br /> � State: Yes ❑ No Iff <br /> Report Mail Address(Required): Contact Name: Phone/Fax: Cell: Sampler:(Please Print) <br /> 225 u,.; iAN- 6lvok.) SOJc. 600 W-ky 303 3?1 LIt34 AI-&k AA4A,42c� <br /> co �z2g <br /> f�,1C.ct.JC�PAt Invoice Contact&Phone: Purchase Order: Quote/Bottle Order: <br /> 0 No Hard Copy Email: 11 2$445 <br /> Invoice Address(Required): 3 UM Q WW-um y Contact ELI prior to S r•Y\ Ilk <br /> o RUSH sample submittal <br /> K O,,,t for ch cOO +Me)- <br /> ao:4SI` Q Q R wring and <br /> a� S � scheduling—See <br /> � <br /> pp w v Instruction Page <br /> ❑No Hard Copy Email: o o, (J <br /> v a .� U ` Yo5nmen <br /> ts R"'' ` �0.7� <br /> Special Report/Formats: '� ..ai`�l€ Q U _v 3•�� `� �. <br /> ❑ DW ❑ EDD/EDT(Electronic Data) �`° H E r <br /> Yffm Q 5 1 Z�l On Ica: r N <br /> ❑ POTWMIWTP Format: =°';i°'o <br /> ❑ State: ❑ LEVEL IV Z E > o w M Custody Seal <br /> w a on Soft N <br /> ❑ Other: ❑ NELAC c' 7 oncOO1er <br /> H C� u Intact N <br /> SAMPLE IDENTIFICATION Collection Collection <br /> Name,Location,Interval, etc. Date Time MATRIX 5�� M Match <br /> N <br /> 64-116 bgso 11 - w X { <br /> 611114 osso it- W x <br /> ' QC'- C. 6 ► 1i4 ttoo it - w o <br /> W 6 t 16 iols It- LJ X <br /> *,4 S r► 61 i 116 a935 1( - LA) <br /> 0 <br /> O <br /> a <br /> O <br /> 00 <br /> a <br /> 0 <br /> +uSlOdy nquisf+�d by(print): DateJTime f Signature: by(print): Dat ire Signature <br /> \ — e� !� <br /> Record Relinquished by ): Date/Time: Signature: Received by(pr y DateRime: Signature: <br /> IIUST be <br /> Signed ugrua ure <br /> g Sam a Dis osal: Return to Client: Lab Disposal: <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 Dossibility All Sub-rnntr-nrt rintn u.in ti...i—ri., — <br />