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KENNEDYMENKS CONSULTANTS ❑200 New Sure Rd 1116 0akersheld CA 93309 116190 Ned Road 1300 Rene NV 89602 <br /> ❑53o South 3381h St Federal Way WA 98003 D 33398tad:hew Rd 1140 Sacramento CA 85827 <br /> SAMPLE CHAIN-OF-CUSTODY ANALYSIS REQUEST C3 17310 Red Hill Ave 1220 Morns CA 92714 0 303 Second St San Francisco CA 94107 <br /> 1]2191 East bayshor•Rd 1700 Palo A310 CA 84303 p 1000 Hill Rdd #200 Ventura CA 93003 <br /> POSSIBLE HAZARDS (5) 13601 3 6O <br /> ANALYSES RED.LIESTF.D {�� <br /> Date 2� 4<t4j?/ hSG Report To Lab Destination f`J <br /> Source of Samples 350 E-__M01"kEt Company ,2 Address U VIC e--f— <br /> �r L'` 00 <br /> o 0 <br /> Sampler N��a[me 5if eey aT Address ,4 ,�/ /t^4y a 4; C <br /> Phone �`"(��1 2 3 [`• 1. A .2i ��. -a Phone ( U 0 — `Q f, <br /> toro <br /> ff /I <br /> Protect No (7b 0 �._4 Phone S z gY7' Z (a11) <br /> —Izs CafnerlWay Bill No <br /> Lit <br /> ;11 {11 COLLECTION 121 131 (41 Turn d 0 Comimont/Conditione <br /> Leh ID No Client ID No Dale True Type Depth Camp Pres around al (Container two.—nto or number,etc) <br /> DzA PB - 1a " Z'Sb s i <br /> 03A ``r X Lc <br /> o4A P6 - I Ir 3.,, s lex <br /> 105A PI? -7,1 <br /> 06A Q— Z6 /Y <br /> 14 1 <br /> (1 I Write only one sample number in each space <br /> 121 Specify type o1 semplell) Water JW) Solid(S) or Indicate type <br /> 131 Mark each sample which should be composlled In Laboratory as follows Place an'A"in box for each sample that should be composited Into one sample use sequential letter for additional groups <br /> 141 Preservation of sample <br /> (5) Write each analyses requested across top Place an"X"in appropriate column to Indicate type of analysis needed for each sample <br /> SAMPLE RELINQUISHED BY SAMPLE RECEIVED BY <br /> Fwd Name Signstum Company Date lime Prim Name Segnatare Company Date Time <br /> 1 A7 t� 6� EryV5, ,4E <br /> tMISCICUST00Yll FAM <br /> Ooam6 m <br />