Laserfiche WebLink
Chain of Custody and Analytical Request Record <br />AMIMU NOW OI CAC= 0011dT- Drnoian - !n-h infnrmnTinn If. <br />nnQCih1A_ <br />Page of <br />Company Nam Project Name, PWS. Permit, Etc. Sample O EPA/State Compliance: <br />6F'?Z- I/U ftfy=?,- 1A J i Al State: Yes ? No,.[_ <br />Report Mail Address: Email: <br />Contact Name: Phone/Fax: Sampler, (Please Print) <br /> --",I l <br />vaf'e N?9v-/ r c / <br />Invoice Address: Invoice Contact & Phone: Purchase Order; Quote/Bottle Order, <br /> S<941 <br />Special Report(Formats - ELI must be notified R12@ ) U o <br />Contact ELI prior to snipped by. <br />,._. <br /> RUSH sample submittal <br />prior to sample submittal for the following: m R for charges and Cooler ID(s): <br /> rn <br />?> :2 851 p Q scheduling - See <br /> 419 ? > _ Instruction Page - 20 , <br /> <br />F1 DW ? A2LA pd.o m <br />o ?im <br />U e <br />o U <br />Comments: ReeelptTemp <br />o C <br />T l Q <br />(Electronic Data) <br />? GSA ? EDD/ED <br />on t <br />? POTWNVWTP Format: m's? rso }i' <br />LU S Yes) No <br />State: ? LEVEL IV <br />? Z E ai <br />? w ? Custody seal Y ? <br />? Other: ? NELAC >l w <br />U) <br />Z <br />H <br />Coop' Bt: <br /> <br /> Intact Y N <br />SAMPLE IDENTIFICATION Collection Collection MATRIX Signature Y N <br />Name, Location, Interval, etc. Date Tim- x Match <br /> <br />2 /Y\ <br />3 <br />4 <br />5 <br />6 <br /> <br />7 <br />a <br />8 ? <br /> 0 <br />9 00 <br />a <br />10 <br />ustody <br /> <br />r <br />e: <br />Relinquished by int): Dat ime <br />Z R ed b (print)Date/Time: ignaf ire: <br /> <br />F <br />i <br />:7 <br />5 D 5 <br />Record Relinquished by pnrri): Dat Received y ( ) Date/Time: <br />MUST be <br /> <br />ned <br />Si evby Laboratory: Date/Time: Signature: <br />g 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.eneravlab.com for additional information, downloadable fee schedule, forms, and links.