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FGL ENVIRONMENTAL CIAN-OF-•CUSTODY RECORD 0 <br /> PROJECT , <br /> (See Reverse for Instructions) NO <br /> r r <br /> PROJECT NAME 01ZkG1ia� " `t rl SAMPLERS u4AM r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES _ ^TAT CODES <br /> (PRINT) DESCRIPTION CODES A Groundwater F bit <br /> r A 40-ml VOA Vial B Surface water G waste '1 standar <br /> ( IGNI B Glass Liter E Brass Tube C Leachate H BlanklSpike 2 5 Fla <br /> PROJECT NUMBER y <br /> / C PWIic 500-ml F Other D Rinseate I Other 3 60 Hour <br /> � RECORDER 1 ` D Plastic Liter E Sa3VSediment 4 Other <br /> G�lT 1)3 ,raylz {jr„r*1P,�f1'% (SIGN) <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS — y <br /> d e g AND . �+ $ :_ <br /> a8 $ PRESERVATION E gY SAMPLE <br /> a o au ¢E E m NOTES ASSIGNED CONDITION <br /> am i e i T1 t �° 2 E >°v BOTTLE UPON <br /> E (' r �, Z NUMBERS RECElP7 NOTES <br /> DATE TIME SAMPLE ID ' i tt- = <br /> IsJi4 IOJy -2 2.C) 'l <br /> r 142r J^ _ ZG ' t` l x--3 Ix -- + <br /> Sa f <br /> /0�7 ;r� J7' x <br /> t��r' `l ` t <br /> yJ <br /> 2 Sf'r ' <br /> 1lc�1 T r' <br /> - L Religt�plshed by,(St nature) ceived S gnature) Date Time <br /> NOTES IMISCELLANEOUS� lr r c !r,?i �y�C r _ ri �� ��� - q,,55 11 <br /> •� R 11 i - r r �� v�f J �� CJ..i i I f f t !"[ ��' Ft <br /> i Relinquished By (Signature) R wed By { t nature) ate Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> 4 Transport Container Transported with this <br /> 4 _ Chain (by Serial No) <br /> Send Lab Results to (Name) <br /> '//�,,_f ;1, • , ,s i :_� r^ l '; = I'✓�= �� �'' (Check Office Below) Verbals Requested Yes El No El <br /> El PAULA / '�" `�f' I �%-' /U ? ❑ STOCKTON El VISALIA � <br /> TEL (805) 659-0910 T TEL (209)'942-0181 TEL (209} 734-9473 <br /> FAX (805) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL (209) 942-0181 • FAX (209) 942-0423 <br /> WHITE Field Copy YEE_LOW Project Cop% PINK Laboratory Cop) <br />