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0 FGL ENVIRONMENTAL COIN-OF-CUSTODY RECORD QB PROJECT <br /> VA LL E�' �(;-�0 (See Reverse for Instructions) NO <br /> PROJECT NAME �'� t'R J SAMPLERSSAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRI Ti DESCRIPTION CODES A Ground Water F 04 <br /> PROJECT NUMBER ff� 4i*• +,t • 'y A 44 ml VOA Vial ti B Surlace Water G Waste k_Siantlard} <br /> 'r ,r {SIGN) B Glass Luer ` rays Tube C leachate H Blank/Spike 2 5 Day <br /> RECORDEF� t- � 7 C Plastic 5W ml cher Q�uueate___, 1 other 3 so Hour <br /> (SIGN) (j !- Cs D Plastic Liter Sot--USediment 4 Other _ <br /> NUMBER OF 15 REQUESTED LABORATORY USE ONLY <br /> CONTAINERS � U <br /> o AND 'IE <br /> `g a PRESERVATION m 8 = 'a <br /> N =r SAMPLE <br /> ati NOTES ASSIGNED CONDITION <br /> E °� BOTTLE UPON <br /> DATE TIME SAMPLE ID " N t y z NUMBERS RECEIPT NOTES <br /> 1 r i <br /> 7 513 a t t <br /> ' <br /> r <br /> E r 1 <br /> 1 <br /> V3,Jb <br /> i <br /> I <br /> I <br /> NOTES I MISCELLANEQUIS �Ft Inquls d bac Ignature) Received By (Signature) Date Time r <br /> c i f k e- - ` ` <br /> P "�, f.3oC Relinquished By (s nature) Received By (Signature) Date Time <br /> _r "^'Cx is"/, � t /S�b� 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 /> Transport Container Transported wdh this <br /> Chain (by Serial No) <br /> i <br /> Send Lab Results to (Name) �� L� '� -;�aG. (Check Office Below) Verbafs Requested Yes ❑ No ❑ <br /> ❑ SANTA PAULA =Gt'l V"5*-1 t>'-_ ❑ STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 .E%j': •t1G/f _ f�r `���y 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 /> WHITL F,,IJ Cup, YELLOµ Prujw Cup, RINK L.,bin,iw,On. <br /> t r <br />