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i???4cl?v Chain of Custody and Analytical Request Record Page of <br />PLEASE PRINT- Provide as much Information as possible. <br />Company Name: Project Name, PWS, Permit, Etc. Sample Origin EPA/State Compliance: <br />.. Lr ?,? State: e-0. Yes ? No F-1 <br />Report Mail Address: Contact Name: Phone/Fax: Email: Sampler: (Please Print) <br />7$ 8 o 6 Dor&Co ?- Suw?L-u a&?ty 7 h u rn kC 11 3o5-71 S'87 3j <br />F ti/oa }' e co <br />Invoice Address: Invoice Contact & Phone: Purchase Order: Quote/Bottle Order: <br />Special Report/Formats - ELI must be notified 1212@)Uff9V1 1D <br />prior to sample submittal for the following: tpm <br />? DW <br />-_ ? GSA <br />? POTWNVWTP <br />D State: <br />? Other: <br /> 0> °OI <br /> o ,, <br />? U) <br />? A2LA wa nt.- <br />? EDD/EDT(Electronic Data) - <br />° <br /> o <br />?j <br />'2 <br />Format: <br />q I <br />? LEVEL IV z' E<10) <br />? NELAC N >I <br />SAMPLE IDENTIFICATION <br />LL i <br />2/,rrrP;d?Z e&x c,4c_ <br />eGrJ7??3 Concre.?c.. <br />e/,r?-465 Uncrtkf- <br />71117P44. csrn crt*e- <br /> <br /> <br />Collection Collection MATRIX <br />Date Time <br />Mpir gs SA x <br />D <br /> <br />N N <br />t <br />'V <br /> Contact ELI prior to shipped °y: <br /> R RUSH sample submittal <br />r 113(s): <br />c <br /> for charges and o e <br />p a scheduling - See <br />W Instruction Page <br />_ <br />; V <br />Comments: Receipt Temp <br />Q ° ° C <br /> - <br /> 7 S <br />V On Ice: <br />Q ~ Yes No <br />W <br /> E <br />(n 0 H Custody Seal Y N <br /> Intact Y N <br /> Signature Y N <br /> Match <br />MUST be <br />ace by Monitory: DateRme: Signature: <br />Signed Sam le Dis anal: 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.eneraylab.com for additional information, downloadable fee schedule, forms, and links.