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AMPLERS: (Signature) <br />CHAIN OF CUSTODY RECORD <br />— <br />— SHIPPING INFORMATION <br />Phone: <br />SHIP TO: <br />Shipper <br />Address <br />Date Shipped <br />Shipment Service <br />Airbill No. <br />ATTENTION: <br />Cooler No. <br />Phone No. <br />Relinquished by: (Signature) <br />Received by: (Signature) <br />Date/Time— <br />Relinquished by: (Signature) <br />Received by: (Signature) <br />Date[ Time <br />Relinquished by: (Signature) <br />Received by: (Signature) <br />Date/Time <br />Relinquished by: (Signature) <br />g <br />Receive for laboratory by: (Signature) <br />I _ <br />Date/Time <br />Analysis laboratory should complete "sample condition upon receipt" section below, sign and return top Copy to <br />Canonie Environmental Services, 83 W. March Lane, Stockton, Ca. 95207 <br />Sample Site Date Analysis Sample Condition <br />Number Identification Sampled Requested Upon Receipt <br />E- ZL 8g <br />White - Sampler Canary - Return Copy To Shipper <br />Pink - Lab Copy <br />