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I• <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> E rk_ (See Reverse for Instructions) NO. <br /> t <br /> r PROJECT NAME ��1 T SAMPLERS m ptilq 't15 SAMPLE CONTAINER SAJAPLE DESCRIPTION CODES .----•—.TAT CODES <br /> DESCRIPTION CODES AAround Water F. Oil / <br /> PROJECT NUMBER r�! )1t L� A. 40-m1 VOA Vial B. Surface Water G. Waste -1-Standard <br /> (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. Blank/Spike 2.5 Day <br /> RECORDER C. Plastic 500-ml F.Other D. Rinseate I. Other 3. 60 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> m o _ <br /> PRESERVATION 11 ya a`o n <br /> = o^ <br /> E°1¢ 6-- <br /> E <br /> r yu SAMPLE <br /> O _ LLL E inU aV <br /> ° Z x _ �; E $ NOTES ASSIGNED CONDITION <br /> ES E= a = :1 - �� C. �' E °L BOTTLE UPON <br /> DATE TIME SAMPLE ID e-1 N =LLtD V— N Z NUMBERS RECEIPT NOTES <br /> 1:250 i'lk.( V(,, t 1 ✓ ►)i� 1�'NC� U- <br /> 4-.. viz 1:3P AtjM k Vc,A <br /> Z :2,F AUe4, VVII` A / <br /> y.p1j.rfZ It '1 OL "i y <br /> NOTES/MISCELLANEOUS Re)ijp uished by- ignature) Received By: (Signature) Date Time <br /> rA <br /> �nn�/ � tP��(r��UC«C�✓/�5 �C�(�4..�;�t�:..�t�.CG.V�C<` /' ! "` <br /> Relinquishe y: (Signature) Received By: (Signature) Date me' <br /> r-- I <br /> Relinquished B (Signature) Receiv (Signature) Date Time <br /> 1 q Y ( 9 ) �� Y ( 9 ) <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched B : (Signature) ate Time Received for lab By: (Signature) Date Time <br /> V1 Transport Container Transported with this <br /> II V. Chain (by Serial No.) r U`t . <br /> CSP�I � 'S3G '�/ "� ,.' �_�`` t_��� �-+t��r�. ���1) �M • ! <br /> Send Lab Results to (Name): C� S t) f � '- 2L0 1 Stk6� Z(Check Office Below) Verbal" R quested: Yes El No El <br /> lSANTA PAULA �p' U33-�- ❑ 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 /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br /> t 11 WHITE:Field Cope YELLOW:Project Copy PINK:Laboratory Copy <br />