Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

CU#Job No.Full Name Fax

Phone

Company

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

CU#Job No.Full Name Fax

Phone

Company

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:MM

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

11586CU#Job No.

Ms. Mari Lynn JohnsonFull Name (925) 625-4033Fax

(925) 513-2373Phone

EcoWaterCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Boro

n

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x

x

MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

4Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

Bedal Property, 1038 Petite Sirah Ln

001

001

001

DW

DW

DW

DW

Pl

Pl

StPl

Pl

950mL

950mL

100mL

125mL

SizeCold

HNO3

Na2SO4

HNO3

1

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site Access

cellEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

(925) 766-6803Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:RL

EDT

7/22/2009

Package General Mineral-Modified

925 766-7184Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

10992CU#Job No.

Mr. Chris HamburgerFull Name (925) 743-1304Fax

(925) 820-6875Phone

Water Tech SystemsCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

CTSampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site Access

Leslie (c)Emer. Name 1Chris (c)Emer. Name 2

Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

925 570-5801Emer.Phone 1925 570-5803Emer.Phone 2

Emer.Phone 3Emer.Phone 4

NOTES:MM

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12047CU#Job No.

Mr. Javier PetrizFull Name 925 463-3113Fax

925 463-3234Phone

DP Air CorpCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

#2 North First Street - San Jose

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

925 580-2293Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12047CU#Job No.

Mr. Javier PetrizFull Name 925 463-3113Fax

925 463-3234Phone

DP Air CorpCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

Broadway - Oakland

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

925 580-2293Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12047CU#Job No.

Mr. Javier PetrizFull Name 925 463-3113Fax

925 463-3234Phone

DP Air CorpCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

Third Street, San Francisco

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

925 580-2293Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

11215CU#Job No.

Ms. Bev TrutnerFull Name (925) 862-2478Fax

(925) 862-2479Phone

Trutner CorporationCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

ZnBo

ron

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x

x

x

x

x

x

MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

6Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Old Well

New Well

Date Sampled Date Due

3465 Little Valley Road

001

001

001

002

DW

DW

DW

DW

DW

DW

Pl

Pl

StPl

Pl

Pl

StPl

950mL

950mL

100mL

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

Cold

HNO3

Na2SO4

1

1

1

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

( ) -Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12007CU#Job No.

Ms. Anna NahlikFull Name 925 454-3380Fax

888 326-9355Phone

Dan’s Water Well & PumpCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site Access

Anna’s (c)Emer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

925 785-2015Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

925 785-2015Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

11968CU#Job No.

Mr. Bob PowellFull Name 408-436-1109Fax

408-436-8386Phone

Goble PropertiesCompany

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

3515 Andrade Road, Sunol

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site Access

Bob Powell (c)Emer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

408-436-1109Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

408 595-4572Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12122CU#Job No.

Mr. Victor Leyva, Total Quality Full Name (510) 785-7573Fax

(510) 783-4118Phone

Mission Foods HaywardCompany

Sample SourceHayward

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:MM

EDT

7/22/2009

Package General Mineral-Modified

(510) 750-4685Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

CU#Job No.Full Name Fax

Phone

Company

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

RLSampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

2800 Camino Diablo Road

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:RL

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

12190CU#Job No.

Ms. Deena FarrahFull Name Fax

925 685-2961Phone

Company

Sample Source

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x

x

MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

4Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

MMSampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Kitchen Sink

Well

Date Sampled Date Due

1420 Mohr Court, Concord

001

001

001

002

DW

DW

DW

DW

Pl

Pl

StPl

StPl

950mL

950mL

100mL

100mL

SizeCold

HNO3

Na2SO4

Na2SO4

1

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

NOTES:MM

EDT

7/22/2009

Package General Mineral-Modified

925 778-2961Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

178CU#Job No.

Mr. Ernest DejesusFull Name (925) 634-3422Fax

(925) 634-3392Phone

Dejesus Pump & Well Drilling, Inc.Company

Sample SourceByron

Alk

EC p

H T

DS C

l NO3

SO4

Hard

ness

Ca

Cu F

e Mg

Mn K

Na

Zn

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x

x

x MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

3Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

Sampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

DW

DW

DW

Pl

Pl

StPl

950mL

950mL

100mL

SizeCold

HNO3

Na2SO4

1

1

1

Site Mgr. Site Mgr.Tel# Cell#Site Access

E. DejesusEmer. Name 1Mr. BotheloEmer. Name 2

Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

CCCHSAgency 925-692-2537Agency # Fax#

(925) 634-5148Emer.Phone 1408 368-9792Emer.Phone 2

Emer.Phone 3Emer.Phone 4

NOTES:CT

EDT

7/22/2009

Package General Mineral-Modified

Cell

Temp. at Lab -oC

Chain of Custody Page of

DW - Drinking WaterGW - Ground WaterSW - Surface WaterWW - Waste WaterWaterSL - SludgeS - Soil

HB - HosebibPV - Petcock ValvePT - Pressure TankPH - Pump HouseRR - RestroomGL - GlassPL - PlasticST - Sterile

10747CU#Job No.

Mr. Randall C. Slusher, Admin. Svcs Asst. Full Name Fax

(925) 313-4379Phone

Contra Costa County, Community Development DepartmentCompany

Sample Source

Cu F

e Mn

Zn

Lead

Asbe

stos

Cl N

O3 S

O4 T

DS

Color

Odo

r Tur

bidity

Bacte

ria (P

/A)

Lab No. Sample I.D. Date Time Matrix Contain. Preserv. Qty.

ANALYSIS

x x

x x

x

x

MATRIX

ABBREVIATIONS

SAMPLE RECEIPT

6Total No. of Containers

Rec'd Good Cond/ColdConforms to Record

CTSampler

Relinquished By: Date Time

Received By:

Relinquished By:

Received By:

Relinquished By:

Received By:

Date Time

Date Time

Date Time

Date Time

Date Time

Date Sampled Date Due

001

001

001

001

DW

DW

DW

DW

Pl

Pl

GlA

StPl

950mL

950mL

250mL

100mL

SizeHNO3

Cold

Cold

Na2SO4

1

3

1

1

Site Mgr. Site Mgr.Tel# Cell#Site AccessEmer. Name 1Emer. Name 2Emer. Name 3Emer. Name 4

ScheduleAnalyte

Emer. Name 5 *See file

Agency Agency # Fax#

( ) -Emer.Phone 1Emer.Phone 2Emer.Phone 3Emer.Phone 4

P.O. No.P27466NOTES:

CT

EDT

7/22/2009

Package General Mineral-Modified

925 525-5531Cell

Temp. at Lab -oC