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• • 1 • <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME SAMPLE=RS Wd 1) ioi4jr t/ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> y� I EPR DESCRIPTION CODES A Ground water F Ori <br /> PROJECT NUMBER A 40-ml VOA Wat B surface water G wesfa Standard <br /> W/(SIGN) 9 Glass Liter E Oras.Tube C Leachate H BlanklSPrke <br /> RECORDER C Plastic 500-ml f Other Q Rinseate 1 Other 3 r <br /> (SIGN) D Plastic tiler SoiVSediment 4 Other <br /> f - <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND m € g + } <br /> 25 5 PRESERVATION <br /> 8 S 9og a�ix SAMPLE <br /> �s 8 : z ¢p ;"—<U NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLEID <br /> �v z 4 N iv - NUMBERS RECEIPT NOTES <br /> " f0 <br /> 10x67 f <br /> O f t /✓ <br /> I <br /> '140 /-1$f/kS - "o C{c <br /> �1 Y t r L <br /> t / 3AI�.n <br /> A + <br /> NOTES I MISCELLANEOUS '} �, ? Reim, shed b (Signature) Received By (Signature) Date Time ~ <br /> 61 A <br /> -12 ' E Reprrriuished By (Signature) Received By (Signature) Date Time <br /> 17 ti, +r a%-:1'1�c <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> i <br /> I <br /> Method of Shipment Description of Other Chains-01-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> 4 .� <br /> A Transport Container Transported with this <br /> Chain(by Serial NO) <br /> Send Lab Results to (Name) ' 1 ' ' ' (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ SANTA PAULA ❑ STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (805) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br /> cfi <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL (209) 942-0181 • FAX (2 }142-0423 <br /> Y <br /> WHITE Ficld Copy YELLOW Project Cop) PINK Labe imy Cul% <br />