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SITE INFORMATION AND CORRESPONDENCE
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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3500 - Local Oversight Program
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PR0544494
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SITE INFORMATION AND CORRESPONDENCE
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Last modified
11/19/2024 10:19:50 AM
Creation date
5/28/2019 8:50:52 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0544494
PE
3528
FACILITY_ID
FA0005978
FACILITY_NAME
STAN MORRI FORD
STREET_NUMBER
104
Direction
W
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95376
APN
23505307
CURRENT_STATUS
01
SITE_LOCATION
104 W ELEVENTH ST
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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SAMPLE CHAIN OF CUSTODY RECORD <br /> DEL-TECH GEOTECHNICAL. SUPPORT (PLEASE PRINT) Lab. Analyses by : TiFdm bt Ar- -_ <br /> 10624 OLIVE AVE. OAKDALE, CALIFORNIA 95361 LAB. INVOICE TO <br /> OFFICE (209) 847-8757 <br /> FAX (209) 847-7744 RECORD __j_OF PH. # 7 a7 r7 kCLIENT / CONSULTANT: {Jwn P.O.#/INVOICE# <br /> QA*vTe:pNL1-1 &IwkANALYSIS REQUESTED _.. SITE SAMPLE MAP <br /> PROJECT I SITE NAME: M A ('!— (ITEAJIZED AND CNECAED BELOW) MT TO WAu) (NORT}I <br /> � t <br /> ii a m <br /> LET= <br /> T: 1 D 1 (� a } CITY: STATE: C A-1 ii o �Q ¢ 0 ::,:1: a MMS I <br /> U C7 cC <br /> � � 7 O OC O <br /> r } f��y�� N OUO O J w <br /> L ]{1j- 'HIP VIA: 1� - ! a <br /> SAMPLE :( INTED SIGNATURE) AYBILL k y I � � �j C, � � a 4I <br /> O ~ cc <br /> o ¢ a x w <br /> Q .w <br /> SAMPL E <br /> NUMBER LD o: s w rx o 0 0 <br /> 5A <br /> I.00AT'ION DATE TIME AlPL F. _ w . r <br /> OF (GRA 8 ORv- r` <br /> (IDENTIFICATION) MTHIDA}IS'R. JIOUR/MJN. ICONTAINERS (}DAJPOSlTE) A1ATRIX m f' REMARKS/* SPECIAL INSTRUCTIONS BELOW <br /> QI L <br /> 13 q3 1 <br /> 3.) - -36$ IND <br /> b-) l 114 Nhis 90 ly <br /> n b ( ID . < <br /> -on) aa � r,� <br /> 9,) <br /> lo. <br /> 1 ••SAAIPJE MTEGRTTI'I CONDITION&TURNAROUND TIAIE •• <br /> qb- <br /> RECEIVED COLD d INTACT / YES 1 ISO <br /> REL NQ Ism,BY s : nreu DATE TIMNI" RECEIVED DATE TIME: <br /> PRESERVATIVES USED a.{,U'ES Y� NO } <br /> CUSTODY SEALS INTACT I YES � � NO � � NA l , <br /> AIR BURBLES IN V.O.A.'S I YES � � No � � L1NE N <br /> RELINQUISH FD B1':nM.nATukT, )ATE I TIME: RECEIVED BY:s,c.,nr„c, ATE I TIME: <br /> TURNAROUND"AE., CHECK ONE <br /> REIJVQClS11M71 B}'' r.Tiroi, )ATEI TIME: _'CEIVED!I1'LABORATORY:, [)A,,,,T <br /> 4 ; ( <br /> n�Tc Tl xn„en.:v.T,+,e� M:!TI\4 H, 7 '-�-HOUR 1 ' AB-IIOUR _-DA}' { la-I)AV <br /> i <br /> NOTE. LABORATORY SAMPLE ARCHIVING WILL BE 30 DAYS FROM THE DATE SAIMPLE WAS COLLECTED,UNLESS OTHER ARIRAINGE TENTS ARE MADE. <br /> PLEASE RETURN DEL-TECH'S ICE CHEST AND BLUE ICE AS SOON AS POSSIBLE.. THANK YOU + DEL=TECH FORM C.O.C. <br /> rs <br /> Pink - Field C(ipy / White & Yell(m, - Ttl I":Ihi)r;lk)r1' wi4h Samples / Ycllow - Return 4),'Choll with Results <br />
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