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w <br />0 <br />Chain of Custody and Analytical Request Record Page of <br />PLEASE PRINT Provide as much information as possibI e. <br />Company Name: <br />a <br />tPrroject`Name, WS, Permit, Etc. <br />Wk-T I <br />Sample Origin <br />EPA/State Compliance: <br />� <br />%et FIA4As Q -U%4TC tS <br />1 %4: �►� <br />State: Col 0 <br />Yes No 0 <br />Report Mail Address (Required <br />Contact Name: Phone /Fax: <br />Cell: <br />Sampler: (Please Print) <br />i�`,r 5...: 4 Goo <br />—Ae <br />uy�ky 6k. t C3o3 - % - Lt �3�� <br />a? k:1b+� 1 <br />La ewo«Jli Coto fta <br />Invoice Contact & Phone: <br />Purchase Order: <br />Quote /Bottle Order: <br />�� ;na <br />❑ No Hard Copy Email: <br />1 <br />Invoice Address (Required): <br />L�w:a� �tvJ stw +� <br />Contact ELI prior to I <br />RUSH sample submittal <br />ll"''J pp° v' <br />FP tit <br />a,3r <br />L4k e. owe solo <br />L'.p <br />° � SI w <br />l9�� <br />Q <br />!Z' <br />R <br />for charges and <br />scheduling — See <br />p <br />cooler Ole): <br />7 (rte <br />lj L 1 <br />0 No Hard Copy Email: <br />0 3 <br />�.a o <br />�Qr„�_ <br />o ml , <br />3 <br />w <br />_ <br />U <br />° <br />U <br />Instruction Page <br />Comments: <br />Receipt Temp <br />° C <br />Special Report/Formats: <br />❑ DW ❑ EDD /EDT(Electronic Data) <br />�-� <br />��°- ° <br />Q <br />M <br />On Ice: <br />❑ POTWIWWTP Format: <br />❑ State: ❑ LEVEL IV <br />Qal � o <br />E 71 <br />b1 <br />w <br />w <br />S <br />custody seal <br />on Bogie <br />❑ Other: ❑ NELAC <br />co <br />.T <br />ti% <br />on cooler <br />H <br />Intact <br />AJYN <br />SAMPLE IDENTIFICATION <br />Collection <br />Collection <br />MATRIX <br />�•% <br />Signature <br />Name, Location, Interval, etc. <br />Date <br />Time <br />Match <br />1 <br />G•y'�3 <br />3ei� <br />Wait <br />.S <br />z <br />3 <br />() <br />4 <br />�f <br />3 <br />6 <br />X <br />d <br />7 <br />9 <br />Op <br />a <br />10 <br />Custody <br />Unttu:ed by {p; t0 }. Dot +e /jrme` /� <br />�t 1l/ Lai <br />• Received by (print) Date/Time Signature <br />Record <br />Relinquished by (print) oate/Time gnatur Received by (print): DatelTime. Signature: <br />MUST b <br />ST b e <br />Signed <br />r° y a a ,rue -grid ure. <br />Sa a Dis osal: Return to Client. Lab Disposal: <br />In certain circumstances, samples submitted to Energy laboratories, Inc, may be subcontract other certified laboratories in order to complete the analysis requested. <br />This serves as notice of this possibility. All sub contract data wit learly notated on your analytical report. <br />fad schedule, forms, and links. <br />4 <br />t <br />