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Chain of Custody and Analytical Request Record <br />PLEASE PRINT- Provide as much information as ossible. <br />Page ,1--of <br />Company Name: ^ r. ??? Project Name, PWS, Permit, Etc. Sample Origin EPA/State Compliance: <br /> scl w fir- f -:b u"q kr-or' State: C Q Yes ? No ? <br />Report Mail Address: <br />?800 49- Lbrada >?4? Contact Name: Phone/Fax: -id s Email: <br />?-? r?rlkt% 1 ? 3D3 $? 33 Sampler: (Please Print) <br />. <br />'' l I <br />S u? 2.ta <br />d A.,?u, <br />( <br />Wo a <br /> <br /> <br />Invoi <br />ce <br />Address: Invoice Contact & Phone: -7 ? _ Y"11-4Z41 <br /> <br />egos QQtvi 'S <br />Purchase Order: <br />Quote/Bottle Order: <br />&S Q it;?t?? <br />d+r?t <br />S <br />Special Report/Formats - ELI must be notified . Mp?3 G3C QMC ? o <br />R Contact ELI prior to <br />RUSH sample submittal Shipped by: <br />rior to sam le submittal for the following: <br />P P 9= 0 iv <br />I! M "M <br />for charges and <br />scheduling - See cooler ID(s): <br /> <br />r <br /> c N W F- <br />• Instruction Page <br /> <br />? DW El A21LA <br />0a ?o <br />i <br />' R <br />J 2 <br />U <br />Q a <br />? <br />Comments: <br />Re<eiptremp <br />El EDD/EDT(Eiectronic Data) <br />? GSA ?c <br />° ca <br />. Q S on lee: <br />? POTWNVWTP Format: £ j <br />El State: El LEVEL IV z' gal> w 0 Yes <br /> l C Q E <br />El Other: El NELAC L C? . W H <br />custody Seal Y <br /> Intact Y N <br />SAMPLE IDENTIFICATION Collection Collection <br />MATRIX Signature Y N <br />Match <br />Name, Location, Interval, etc. Date Time <br />&/4TP -01 S©;1 & Aw06 So i l x <br />2 <br />&j <br />2 sd/ <br /> <br />f <br />J <br />ME <br />3 ;* <br />/I TJP -'s O <br />n <br />#4 sa; Soy' / <br />5 <br />? so <br />J 52 <br />6 <br />a i <br />l rb <br />W(o S <br />So; <br />o <br />JJJ <br />c <br />1 <br /> <br />' <br />3a? 0 <br />o <br /> <br />szl oD <br /> / a <br /> <br />us o y inquished by 'nt Dat ime: ignature: a ived by (print): DateRme: Sign <br />t <br />tfl'?, <br />Record elinq hed by (pnrd): Dat ime: ure: eM by pnn : Datefime: ignature: <br />MUST be retory DateRme: Signature: <br />Signed Sample Disposal: 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 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.