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amlY� <br /> c t � <br /> `I <br /> t� FGL ENVIRONMENTAL ( ]C AJN-OF-CUSTODY RECORD <br /> �t�e Pi�o.lECr <br /> "� 1( (See Reverse for Instructions) NO <br /> PROJECT NAME'!�` " A�_ , f� SAMPLERS-_ �` .j � ` SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PROJECT NUMBER, jam,]_ A� /��1� �'�, �� �- DESCRIPTION CODES A.G:a ne wa,er F.o l <br /> ,,T7-ISI-- !!! 1.,.�- A...nn,VDA Vial B.Surface Water G.Waste 1.Standam <br /> /�f/"t <br /> NOT <br /> G�,�( C,/r WNI B Grass firer E.Brass Tube C.Leachate H BlanuSP�te 2 5 day <br /> RECORDER! C.PIa IC SW m1 F.Other.._---_. 0.Rinsuarn I.Ober__ ._.. a Eo Hear <br /> (StGNI D. Plastic Liter E.SavSed—m a.Omar.- _ <br /> NUMBER OF LYSIS REQUESTED LABORATORY USE ONLY <br /> .. - CONIMNERS <br /> 2AND ? 5 <br /> a- PNLSERVATION Y_ <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> D TE TIME SAMPLE ID Iv S BOTTLE UPON <br /> = NUMBERS RECEIPT NOTES <br /> _ <br /> HL. <br /> , <br /> —46r <br /> u a 1 k� <br /> t _ P <br /> f V <br /> - I <br /> -- I s sY � <br /> NOTES l MISCELLANEOUS + : i (9elinquishod by:(SaturB) Received By:(Signature) pale Time <br /> �U} tF �Ulv 1 ,;` ! <br /> i ,•:,t r r,se�t� ca C y Relinquished By:(Sigaa,ure) Reeoived B Si nature r Date Time d <br /> +� h7.� r( s ) <br /> Lit iC4�r- Relinquished By:(Signature) Ret0'ed By:(Signature) Date Time <br /> Method of Shipment DeseripGon of Other Chains Of•Custody Dispatched By:(Signature} pate Time Received for lata By:(Signature) Date Time <br /> Transport Cant iRer Transported With this <br /> f7- Chain(by SRriat leo.) <br /> Send Lab Results to(Name): (Check Office Below) Verbats Requested: Yes ❑ No ❑ y <br /> ❑ SANTA PAULA STOCKTON <br /> TEL(805)6,&90910. VISALIA <br /> TEL (209)942-0181 <br /> TEL(209)734-9473 <br /> FAX (805)525-4172 FAX (209)942-0423 FAX (209)738-5273 ra <br /> FGL ENVIRONMENTAL LABORATGRY•2500 SPAGECOACH ROAD•STOCKTON,CA 95215•TEL.(209)942-0181 • FAX(209)942-040-1 °l <br /> W$1Th:Fxld Cry YELLOW:Pn jm GT) PINK.I.Nv Wry Cly <br /> el <br />