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Chain of Custody and Analytical Request Record <br />Page of <br /> <br />Company Name: F'LCA.7C Yr1:17 ?' rl vllw6 as nwi.n " Iowa.vn as v <br />Project Name, PWS, Permit, Etc. <br />Sample Origin <br />EPA/State Compliance: <br />60ye', J101 State: CD Yes ? No ? <br />Report Mail Address: Contact Name: Phone/Fax: Email: Sampler: (Please Print) <br />78Da 61 ,Dar&do P16-C-C Sui1?-2?? 77t1A rlk-?U 3D3 71S 9733 <br /> <br /> <br /> <br />O!c <br />'LrIkelt <br /> <br />7 «. co <br /> <br />w <br />Invoice Add s: Invoice Contact & Phone: Purchase Order: Quote/Bottle Order: <br />. 4S Q.6-- <br />Special Report/Formats - ELI must be notified Qap I[,?'j?p? p[Q(t?1 [i ? Contact ELI prior ?" dbM <br />RUSH sample submittal <br />prior to sample submittal for the following: <br />N (D <br />ILA o m <br />R ooler Mile): <br />for charges and <br /> a)>, p Q scheduling - See <br /> NW (o W <br />U Instruction Page <br />a <br />i <br />tr <br />m <br />F1 DW ? A2LA a nl? N U Comments: e?e <br />p <br />e <br />p e <br />Z <br />F1 GSA El EDD/EDT(Electronlc Data) al <br />S C <br />on lee: <br />El POTWMWTP Format: (? <br />e- ?-? Q <br />N <br />Y <br />8 <br />? State: El LEVEL IV z' E<lw 1 w o <br />es <br />? Other: El NELAC <br />>I <br />in <br /> <br />w <br />(/) <br />H <br /> <br /> <br />ustody Seal Y N <br /> Z Intact Y N <br />SAMPLE IDENTIFICATION Collection Collection MATRIX Signature Y N <br />Match <br />Name, Location, Interval, etc. Date Time <br /> <br />2 O <br />N <br /> O <br />3 <br />4 vL <br />5 <br />8 <br />O <br />7 <br />a <br />8 <br />O <br />9 <br /> v <br />10 <br />Custody FLefinqtAshed (print): DateTme: Sbrk#Ure: Recei by (print): Daterime <br />CJ_ : <br />1 iyn u <br />Record elinq by (print): at ime: nalu ecerv by pn DateTme : Si <br />MUST be ece ved by La ratory: Date/Tune : S ignature: <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.enerciviab.com for additional information, downloadable fee schedule, forms, and links.