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-wc7=I sz I Please send results to: <br /> SAN jOAQUIN COUNTY <br /> e Z� Name: <br /> �. <I ENVIRONMENTAL HEALTH DEPARTMENT Email: kfofev(asicehd.com& 91')Ve.l1Gtl2SjCehd•c <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Fax: (2C-1)1+io3 43-�3- <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> • 4��F oR� •• 'EHD staff to call for further instructions:Garrett Backus <br /> (209)468-2986, <br /> CHAIN OF CUSTODY RECORD (209)468-3451•MichelleHenry(209)468-3453,Kasey Foley <br /> Sample container description _ Required analysis <br /> TA number. (q o <br /> 0 <br /> Sampler's name: S- c i v F <br /> '} o + " <br /> ° u7 4 <br /> Title: SY - S ` m Z O <br /> C7 ,c d Z LL O Q N F- <br /> Unit: -4-x•1- v N U Q <br /> ° a o N L <br /> L Lt <br /> Sample address <br /> E r o Z V1 l 0 <br /> o v > Z a Q o v Cc: <br /> U c C Q T O <br /> Facility name: A 1 C(' � � �>j <br /> CL o ° r u Z LL E G <br /> u <br /> Facility address: S-t-D E <br /> a <br /> N a d 0 v :° a r <br /> /�t, E „ g a u LL u v v <br /> Facility contact: �ll Y I ° M v tt c E > 3 <br /> N — ° d '� <br /> O O C CL V= Z "- N E CL E 11 7 <br /> Sample Sample source Date Time a m n v Z E ` c v c o r <br /> Sample location , w �„ u !� c C a <br /> number description s mpled sampled - <br /> AICC-CD <br /> at�(rurn �� R I2:[: N «GU2 - X <br /> Name Title Date Time Remarks <br /> Relinquished by: S f� � /o,'�� %7 <br /> Received by {fir G1-1 5-1 S 1 6 ' Z <br /> r <br /> Relinquished by: Ai q- r*M/e4r A-IS-14 /��•46 <br /> Received by:eA�� O7'rl CQ/(/tQvt�ZgFi2 q-I S'� 1 3.1 L/y <br /> R jnquished by: <br /> Received by: <br /> Rev 07/31/15 CHAIN OF CUSTODY <br />