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CHAIN OF CUSTODY FORM <br />Chevron Environmental Manaaement Comoanv ■ 145 S. State Collene Boulevard ■ Brea, CA 92822-2292 COC I of <br />Chevron Site Global ID: <br />Chevron Consultant: Wayne Pem, Inc <br />ANALYSES <br />REQUIRED <br />30 69 awl <br />Address: 8281 Commonwealth Ave. <br />Special Instructions <br />Chevron Site Number. <br />(v 85�f T,2ra� T5' pa(exwr�y � ,ST�c.icTo �� <br />Buena Park. CA 90621 <br />Consultant Contact: �• C^ R-0- "�� <br />At <br />Chevron PM: J - CAvEnrESS <br />Consultant Phone No. 714-826-0352 <br />Chevron PM Phone No.: <br />Consultant Project No. <br />Sampling Company: Wayne Perry, Inc. <br />Sampled By (Print): MAz-L-4 E5—V=10 <br />W <br />Sampler Signature: <br />o <br />w <br />■ Retail and Terminal Business Unit (RTBU) Job <br />,�, <br />Test America Lancaster <br />Other Lab <br />Temp. Blank Check <br />Charge Code: NWRTB <br />■ Irvin CA Laborat s <br />m <br />o <br />Time Temp.. <br />❑Colton, <br />1FF <br />Q <br />(WBS ELEMENTS: SITEAssMT: A1USITE MONT.:OML/REMD. <br />Lab Contact: ancaster, PA <br />�. <br />n <br />w <br />— <br />p"' Ar -`h KRB <br />IMPL.:R5UOP. MAiNT. & MON.: MIL) <br />Phone No: ab Contact Teresa <br />LU <br />■ (949) 261-10 C ' ham <br />m <br />❑ <br />- <br />29i <br />❑ Construction/Retail Job <br />❑ (909) 37 67 Phone <br />`� <br />k9 <br />N ob <br />❑ (717) 656 <br />= <br />p <br />— <br />TN15 IS A LEGAL DOCUMENT. ALL FIELDS MUST BE FILLED OUT <br />X / Z 3 <br />a <br />a. <br />O0 <br />V <br />CORRECTLYAND COMPLETELY. <br />� <br />m <br />m <br />9CM <br />v <br />a <br />- <br />SAMPLE ID <br />Sample <br />Time <br />Container <br />Type <br /># of <br />Containers <br />Preservation <br />Co <br />w <br />m <br />w <br />x <br />Field Point Name <br />Matrix <br />Top <br />Depth <br />Date <br />mmdd <br />Notes/Comments <br />� <br />Z_ <br />Z <br />x <br />cC <br />• <br />a oS o <br />1110S <br />l3��t s�Gw <br />X <br />� <br />_ <br />y <br />w <br />v <br />Coy Date/rim <br />1 Relinquished Bym <br />Relinquished To Company <br />Turnaround Ti . <br />_ <br />4-7 O /S 3� <br />�qudBy <br />Date/Time:: �_ <br />24 Hours Standard ❑ <br />48 hours ❑ Other ❑ <br />> ompany Dat ime: <br />Relinquished To Company <br />Sample Integrity: (Check by lab on arrival) <br />Relinquished By Company Date/Time: <br />Relinquished To pany <br />Dalefrime: IS;D <br />Intact: Onice: Temp: <br />COC.doc, 11/02/09 <br />