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12.1179 tRw 21991 <br /> Pae is Gas and EnvlromwatlA Affahs <br /> .19 Elocft Company- <br /> Chain of Custody Record :1 a a,�� 12 <br /> From: Pacific Gas&Electric Com anyPG&E Facility 0Sample Site Ship To: Lab Name: <br /> Address or Location: �L 1, S Address:_ L Q A+ <br /> City: Il0 1+— <br /> CA (zip) City: J�/ems+ _„ , CA 2i 9 t/,1 3 <br /> Contact Name/Phone No.: 7 Z9- Z Phone No. t IF Zr- VP 1/-'70f <br /> 7-- Contact Name: c <br /> Turnaround Time �1, `I Analysis Requested <br /> NORMAL(10 days or less) []RUSH ❑OTHER,Specify <br /> bue bile d 73oteVV <br /> TELEPHONE [ FAX Give Results to:, et 70-1-;3.7— Q <br /> Name K/FAX <br /> Pe Name: c. Supervisor ame/Phone No.): <br /> e_ sa 1 )oi"s Prvjec e r-r _G 70'7 - 7 Z . <br /> Sampled by: (Signa ) (Prin .Name) <br /> (- c, <br /> Sample No./ Sam ted Containers <br /> Equipment Serial Date Time Sam le Type/Description No. Size Remarks <br /> 1.-- <br /> ............. 7 Zlf�! /F f _ t%��^. LjS -- �_ Sta i. ----------------------- ....... <br /> -- � .•-- ----- ----- - - ----- ---- ----- ------`--------------------------------- <br /> /r ,. <br /> ------ ----------•-------- -------- -------- ....------------------------- . -------- --------- .... .......--- ----- ---- ----- ---- ----- ------------------------------------------ <br /> ------------------------------- -------- --------- ---- ---- ----- ----- ---- ----- ---- ----- ------------------------------------------ <br /> --------------------------- <br /> I11. '---------------------- ----_. ....-- ------------............------ ------- ------- --- --- -- --- -- -- --- -- -1........................................ <br /> 1-- ---------------------- ------ ------ ----------•- ................. ------- -------- ---- --- --- --- -- -- ---- ---------------------------------------- <br /> I'nquishqii ame t. . &� ate&T' !ZZ Received�Et me&Dept.):` I I Date Time: !Z ip Via: <br /> lin e by e& epf.): &T me' A � Received 1.): Date&Time: S' B111 of I adinglAirbill No.: <br /> Re nqu s 1.}: D-ete&i r--.9 /,5 6 Received by(Name a Date&Time: <br /> C �- <br /> SAP Accounting Da a: Billing Contact: to '� Billing Address: 9 <br /> eP 9C C- �G , a�9 9 C' 4-53 <br /> Notes: 1. Samples are discarded by the laboratory 90 days after results are reported unless other arr �gements are made. Distrib�ltion (See note#5) <br /> 2, File a copy of this Chain of Custody Record,complete with appropriate laboratory signatures,with the test analysis results. White: Laboratory <br /> 3. The first"Relinquished by/Date"is the shipping date unless otherwise noted. Canary. Originator <br /> 4. The final PCU results will be the cumulative results added together for each PCB. Pink: Sampler <br /> 5. When this form is computer -generated,send the completed original to the laboratory,and make copies for the originator and sampler. <br /> ®PG&E November, 1998 <br />