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Field Sample Chain of Cusp f Record Kennedy/Jenks/Chinon <br /> Laboratory Division <br /> Source of Sample (s) 1a m I rl4-1 n1y/ ✓D-?V/ K/J/C Job No. <br /> !� L Collector S. x!/6'6✓) <br /> Address � hd/Lrry�16(61 P. a: Affiliation <br /> r7/I Address 3(o 8y-ad 7 Y.( OIL,5t.-- l4+ <br /> Phone ��YIC/Gl!/Y)Pvl� u%r7 /J�U7` <br /> Report to Phone <br /> Sample Information (1) <br /> Lab No. Field No. Date Time Type Depth Remarks(Suspected Contaminants, Con- <br /> (Lab Use Only) _ (2) tainers, Preservatives, Field Conditions, etc.) <br /> B-1 8 Z MY) <br /> 16 ,4 <br /> J9�f� <br /> Chain of Possession <br /> Relinquished by Date Time Received by(3) Date ;;'Time <br /> (Signature and affiliation) (Signature and afffiliation) . <br /> 2. <br /> Logged in at K/J/C by <br /> (1)A separate Laboratory Analysis Request Form is to be filled out by the collector and given to the laboratory when samples are delivered. <br /> (2)ag.water,sludge,soil,etc. <br /> (3)If any samples are not intact at time of transfer,please describe on the back of this form. <br /> Each batch of 10 or fever samples of each matrix type(soil,water,etc)must include enough of one sample for triplicate analysis. <br /> WARNING These samples contain unknown chemicals which,upon analysis,may be determined to be"known to the State to cause cancer or reproductive toxicity;' <br /> under the California Safe Drinking Water and Toxics Enforcement Pct of 1986(Proposition 66). Lab-6(LAB) <br /> Note:Top(Original)copy to laboratory with samples. Rt .12188 <br />