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Please send results to: <br /> SAN JOAQUIN COUNTY <br /> >, . � •o <br /> Name: <br /> i k `j ENVIRONMENTAL HEALTH DEPARTMENT Email: kfolev@sicehd.com& -,nyQ Yateehd -M <br /> 7. '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �` P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd Fax: �Z�1�4iaSy- 3�13� <br /> r F oR 'EHD staff to call for further instructions:Garrett Backus <br /> CHAIN OF CUSTODY RECORD 1 (209)468-3451"(209)468-2986,Michelle Henry(209)468-3453,Kasey Foley <br /> Sample container description _ Required analysis <br /> TA number: (I-7 tfi ( <br /> clA <br /> Sampler's name: S— 0,� I v c? W <br /> u <br /> � v <br /> N <br /> Title: SY }� S (Da z Co o_oF p� v <br /> U i— m <br /> Unit: U a) N <br /> 7) <br /> o ? } = vii N c <br /> Sample address 0 v J <br /> z ai <br /> 0 N C j 0 Q w Li.. OYl <br /> Facilityname: 00 :° c >o <br /> 1 �, o v v <br /> v �7 l V "rbC`t= �1 E a) v L <br /> Facility address: r• m n_ ❑ v v O v <br /> w N LL N N <br /> �e N <br /> Facility contact: �C.� �l.✓ 'a ,ton _ � u 0 Z v o v _ I <br /> 0 0 c n = "= r, o f <br /> L fl. i d Z E O C Y L <br /> Sample Sample source Date Time v N k F N M ;� m a rn <br /> number Sample location description s mpled sampled (iz ~ "' ~ <br /> ;'?cja(C(funq l� G5 I2:� ►rl (Wb� IX <br /> m <br /> Name Title �j Date Time Remarks <br /> Relinquished by: . t� �� � � _% �✓ L- � � <br /> Received by 6 3 Z <br /> Relinquished by: t <br /> Received by: <br /> Rdlinquished by: <br /> Received by: <br /> Rev 07/31/15 CHAIN OF CUSTODY <br />