DEQ-CFW_00071322

Ter�erica Denver
4955 Yarrow Street
estA enco
Arvada, CO 80002
Phone [phone] Fax [phone]
Chain of Custody Record
Sampler: I I "D
Z
Lab PM:
Carrier Tracking No(s):
COC No:
Client Information
/ ,i'C
Johnston, Michelle
Client Contact:
Mr. Michael Aucoin
Phone: q
�C1 7 /���j��
E-Mail;
[e-mail]
Page: �®
Page I of J_
Company:
Job #:
The Chemours Company FC, LLC
Analysis Requested
Address:
Due Date Requested:
Preservation Codes:
c/o AECOM 4051 Ogletown Road, Suite 300
A-HCL M-Hexane
8 - NaOH N - None
City:
TAT Requested (days):
Newark
10 Business Days
,a�
1
C - Zn Acetate 0 - AsNa02
D - Nitric Acid P- Na204S
State, Zip:
19713
E-- NaHSO4 Q - Na2SO3
F -McOH R-Na2S2SO3
Phone:
Phone:
PO #:
302.781.5873
LBIO-67048/84202000-2231 QS1000
O
?'.
G - Amchlor S - H2SO4
H -Ascorbic Acid T - TSP Dodecahydrate
1 - Ice U - Acetone
Email:
WO #:
[e-mail]
�
�O:
m
J - DI Water V - MCAA�
K - EDTA W - ph 4.5
L - EDA Z - other (specify)
Project Name:
Project #:
FAY-NC-DWR HFPO-DA Sampling
28016914
iv
rn
c,
0
Other:
Site:
SSOW#:
E
22
O
Sample
Matrix
Type
(w-wet
U.
Sample
(C=comp,
s-soca
o a,e< i
9
.!
o-
Sample Identification
Sam le Date
Time
G= rab
BT=Tasue,A Ak
tT
:40(i
i
F:
Special InstructionslNote:
;T-W-11-7
Preservation Code:
N
5/3
As1-Z
P - ld 0
1.
1
(� L ._,�Vllsb
_0013.3-
7 �j/lee- -12 ;0isivel
- 7-1
10H
Pnn T t ' ' —i /UShe-
'7-X-17
10 5'
i )"i D glonkg-t7
d s
0S"
r
Pos ible Hazard Identification
Sample Disposal (A fee may be assessed if samples are retained longer than 1 month)
Non -Hazard = Flammable = Skin Irritant = Poison B Unknown Radiological
= Return To Client = Disposal By Lab Archive For Months
Deliverable Requested: I, 11, 111, IV, Other (specify) Level IV
Special Instructions/QC Requirements:
Empty Kit Relinquished by: , (4' _ _
Date: ? l
Time: f
Method of Shipment:
Relinquished by:
Date/Time:
—/ }
Company
Received by:
Daterrime:
Company
7
7 ^ l ! 5`
—
Relinquishe b -
Daterrime:
Company
Received by:
Daterrime:
Company
Relinquished by:
Daterrime:
Company
Received by:
Daterrime:
Company
Custody Seals Intact:
Custody Seal No.:
Cooler Temperature(s) °C and Other Remarks:
A Yes A No