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M "Mirm MMIM <br /> KENNE OYMENKS CONSULTANTS ❑20o clew Slim Rd 8116 Bakersfield CA 93309 ❑fit 00 Neil Road 8300 Rene NV 89502 / <br /> 0 630 South 339th St Federal Way WA 98003 ❑3336 Bradshaw Rd 8140 Sacramanta CA 96827 <br /> SAMPLE CHAIN-OF-CUSTODY ANALYSIS REOUEST 0 17310 Red Hill Ave 0220 benne CA 92714 11 393 Second St Son Francisco CA 94107 <br /> ❑2191 Ent Barshora Rd 0200 Pale Alta CA 94303 Q f n00 hr8 Rd 8200 Venture CA 93003 <br /> POSSIBLE HAZARDS (5) 460 c? —3-7C? <br /> ANALYSES REQUESTED f <br /> Date 1 e w 6 G Report To _ 5{e c T7�aC Lab Destination <br /> Source of Samples Company ' —D Address �C1L U <br /> Sampler Name Address � 7 tJ 5 j _ t�1 Pk q <br /> Phone Cyr 1 — ZG� �.> CIO —r <br /> a, A Phone G (, d <br /> CO [/ <br /> to <br /> 1 t1 v <br /> Protect Nn Phone l 1 ? 7 1 4r 4 cu <br /> C Uf m Q Carrier/Way Bill No <br /> (1) 111 COLLECTION 12) (3) 14) Turn- 0 T X U J <br /> Lab Ip No Glen!1D No, 0. 0. 0. f' O O O Commient/Condluone <br /> pate Time Type Depth Come Pres around F- F F- F- fid > 1-- 7 (Container type.container rxrnlber.eta) <br /> a, a t L 112 <br /> >n <br /> U'' _ rI 1;r �� It <br /> U411f l [' 7-0 S <br /> USSn <br /> ` 117QG l r <br /> U-74 1 N ' <br /> ll , <br /> ILI t t I I <br /> Iii Wnte only one sample number In each space lna� -—,71:: —.41 u wt (zV7 7-/ <br /> 12) Specify type of samplelal Water{W) Solid(Sl or Indicate type �T <br /> 131 Mark each sample which should be composited In Laboratory ss follows Place an'A'in box for each sample that should be composited Into one sample use sequential latter for additional groups <br /> 141 Preservation of sample <br /> 150 Write each anslyeas requested acmes top Place an'X'In appropriate column to Indicate type of analysis naaded for each sample <br /> SAMPLE RELINQUISHED BY SAMPLE RECEIVED BY <br /> Phnit None ftnetum / Convainy 011".- <br /> eteFT-kni-F Print Name SK"Urb a Company Date Time <br /> tYrsgCtlsraDy7 FNfa <br /> W0006 <br /> 00 <br />