APPENDX C Chain of Custody Forms
CHAN OF CUSTODY Servkes AE,rpo OWdL 1317 South 13th Ave. Kelso, WA 98626 (360> 5777222 (800) 6957222x07 FAX (360) 6361068 SR#: PAGE _ OF 000# PROJECT NAME,'r j PROJECTNMBER PROJECT MANAGER COMPANY ADDRESS CTY STATE S P EMALADORESS PHONE# SAMPLERS '. _ AMPLE.D. DATE ME LAB.D. MRX_ 7 O o,o 0". las) O' _ & p, '!q!1 L!,,. k.... _.. _. NVOCE NFORMATON Circle which metals are to be.jzed: REPORT REQUREMENTS P.O#, Routine Report: Method Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se S r T Sn V Zn Hg Bill To: Blank, Surrogate, as _ Dissoved Metals: Al As Sb Be Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg * NDCATE STATE HYDRO CARBON PROC EDURE: AK CA W NORTHWEST OTHER : ( CRCLE ONE ). Report Dup., MS, MSD as TURNAROUND REQUREMENTS 24 hr. 48 hr. SPECAL NSTRUCTONSCOMMENTS: ll. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V. EDD Requested Report Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: Signature Time Sture ateti Tnature DTme Signature DateTime Printed Name Firm Printed Name Firm Printed Name Firm Printed Name Firm RCOC #1 0603
CHAN OF CUSTODY Servi( Os A, Ep,r o rrp 1317 South 13th Ave. Kelso, WA 98626 (360) 5777222 (800) 6957222x07 FAX (360) 6361068 PROJECT NAME PRO, ECT NUMBER _ PRO ECT MANAGER S R#: PAGE _ OF 000# t & COMPANY ADDRESS o; * y, C TY STATE ZP EMA LA DRESS Y _ t\e 1G55) & 9o PHONE FAX 0 'w, cc dj o s, c., SAMPLER'S S ONAT RE eqcoo0co _ SAMPLE D. _ DATE TME LAB D. MATRX, i _!Z KS 4 REPORT REQUREMENTS NVOCE NFORMATON Circle which metals are to be ana(d.. Routine Report: Method Bill To: Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg Blank, Surrogate, as _ Dissolved Metsis: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg * _ NDCATE STATE HYDROCARBON PROCEDURE: AK CA W N O RTHWEST OTHER: ( CRCLE ONE ). Report Dup., MS, MSD as TURNAROUND REQUREMENTS 24 hr. 48 hr. SPECAL NSTRUCTONSCOMMENTS:. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V. EDD ReqUested eport Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: gndtlr'e Dteie Deime Sire DaTime Signature Dirne Printed Nam Fern infm' Firrn Printed Name Firm Printed Name Firm ACOC #1 0603
CHAN OF CUSTODY $olumbia Analybi a! L Services Anpior (E, 1317 South 13th Ave. Kelso, WA 98626 (360) 5777222 (800) 6957222x07 FAX (360) 6361068 PAGE PROJECT NAME PRO ECTNUMeER PROJECT MANA ER C) COMPANY ADDRESS CTY STATE S P PHONEE SAMPLERS SONATLRE SAMPLE D. DATE TME &'C MAT ADDRESS 7 4 1 PAS & Go 0w, :w LAB D. MATRX :: SR#: OF _ 000# # Jo tj, _ REPORT REQUREMENTS NVOCE NFORMATON PO # Circle which metals are to be analyzed:. Routine Report: Method Bill To: Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg Blank, Surrogate, as _ Dissolved Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K A g Na Se Sr T Sn V Zn H g *NDCATE STATE HYDROCARBON PROCEDURE: AK CA W NORTHWEST OTHER: (CRCLE ONE). Report Dup., MS, MSD as TURNAROUND REQUREMENTS SPECAL NSTRUCTONSCOMMENTS: 24 hr. 48 hr.. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V.EDD Requested Report Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: S gnaturc DateD me nature Dateie nature ime Signature Dateime Pruitod Name Firm Printed Name Firm )nted Name 1T PrinffName Firm RCOC #1 06 03
,4ji' a Sample Transportation Notice Relinquishing signature on this document indicates that sample is being shipped in compliance with 180 BLUE RAVNE ROAD, SUTE B all applicable local, State, Federal, national, and international laws, regulations and ordinances of FOLSOM, CA 956304719 L7DC any kind. Air Toxics Limited assumes no liability with respect to the collection, handling or shipping '916) 9851000 FAX (916) 9851020 of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, CHANOFCUSTODY RECORD and indemnify Air Toxics Limited against any claim, demand, or action, of any kind, related to the Page of collection, handling, or shipping of samples. DOT. Hotline (800) 4674922 Project Manager Project nfo: Turn Around Time: 7 Collected by: (Pdnt and Sign) 1 P.O. # J Normal Company Email Project# JRush V_i Address City State Zip Phone. Fax _..._ Project Name _ specify Date Time Canister PressLre"cuum Lab LU Field Sample LD. (Location) Can # of Collection of Collection Analyses Requested nitial Fin _ Rl nquk ied by: a gnature) DateTime Received by: (signature) DateTime Notes: Relinquished by: (signature) DateTime Received by: (signature) DateTime Relinquished by: (signature) DateTime Received by: (signature) DateTime Lab Name Ar Bil Temp C Condition Custody bedis l!tc'l Yes No None i._ H orm 11
g Air TOKCS L1D CHANOFCUSTODy RECORD Sample Transportation Notice Relinquishingsignatureonthisdocumenfindicatesthatsampleisbeingshippedincompliancewith 180 BLUE RAVNE ROAD, SUTE B all applicable local, State, Federal, national, and international laws, regulations and ordinances of FOLSOM, CA 956304719 any kind. Air Toxics Limited assumes no liability with respect to the collection, handling or shipping of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, ' 916' 9851000 FAX '(916 9851 20 and indemnify Air Toxics Limited against any claim, demand, or action, of any kind, related to the collection, handling, or shipping of samples. DOT. Hotline (800) 4674922 age Project Manager.. Project nfo Turn Around Time: Collected by: (Printandsn 1 P.O. #_ Normal Company Email Address Project# _ Rush _City State Zip 4 Phone Fax _ Pioject Name _ sr ify Date Time Canister PressureVanuom i o Field Sample D (Location) Can # of Collection of Collection Analyses Requested nitial Final Piss.: Re nquished by: (signature) DateTime Received by: (signature) DateTime otes: Felinquished by: (signature) DateTime Received by: (signature) DateTime Relinquished by: (signature) DateTime Received by: (signature) DateTime Lab Shipper Name Air Bill i Temp ( C) Condition Custody Seals ntact? Su Srcl:. Yes No None Form 1293 revil