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u <br /> SAN JOAQUIN COUNTY <br /> � Please send results to: <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Name: I V YZ( <br /> (rFON <br /> Telephone:(209)468-3420 fox.(209)468-3433 Web:www.sjgov.org/ehd Email: srly a _ SIoCevil .cor <br /> Fax: <br /> CHAIN OF CUSTODY RECORD z3 K1 '8D3 <br /> /'I Sample container description Required anal is <br /> RO number. I VI/n�1 45f'4 E <br /> n �� 8 <br /> me: I V r� v� <br /> Sampler's nag <br /> A ? C ry <br /> Title: SY• R S C <br /> 7 p n o y <br /> c z <br /> Unit: �'L'.l�i�PA <br /> « ' q <br /> � q d av <br /> Sample address n c ' p <br /> ` = 0 v i <br /> rye L <br /> Facility name: r'�n n dOl-Q,�vl ' �( 1 I 'b� C ao 1° Qp <br /> pL ? q <br /> n o u r d 2' <br /> Facility address: -ve_ N n� .. 'c r w E o <br /> v <br /> Facility contact: EA LC� ?V + O M q a tf w <br /> a ? d, <br /> Sample Sample source Date Time ° c° <br /> Sample lotion vm rnnumber description tripled sampled ^ <br /> ` PAS" 7rai lcr rkcl soli 111513 0113am Ca X -01 <br /> lo�ac. a I5 13 �:� G oc. v� <br /> So1L Wh(ellawno reciGGsvi 11 l� 13 q: 5c�t G0ZC <br /> -03 <br /> . /,�1 e.r 540. 6r „p -5)1 <br /> ty1l IZ <br /> 1 `0�OL �I e O `" Title Date Time Remarks <br /> Relinquished by: S 1'aC, �e. jtQ (Z ' ) /t 1 /a �„J _ / 50 /I <br /> Received by /�"� -'21 <br /> Relinquished by: rl 'r� II-IS�l3 1p;27Dom,,, <br /> r <br /> Received by: //.,/C1_/3 /0: 0-114 <br /> Relinquished by: 11 J .G/ <br /> Received by: <br /> Rev O6/05/13 <br /> CHAIN OF CUSTODY <br />