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r7`7 r—t r7" r—" r--„ r--P r--'I" r-* r--! r-••" F—" r-- r""' F—. r--'? r— r—. r--7 <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> y� �^ f. &r(See Reverse for Instructions) NO. <br /> 'ROJECT NAME Co/J�I-e re 1�, SAMPLERS ChZ e57 1 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q C .�L r RINT) DESCRIPTION CODES & Ground water F. oa <br /> 'ROJECT NUMBER 4/.+ / s�l�G1S��i A. 40-ml von vial B. Sueace water G. waste I. Sla and <br /> p C� �` (SIGN) B. Glass Lit. . Brass T C. Leachate H. BlankISIAo Iay <br /> RECORDER C. Plastic SOI}ml S.Other ..... 1. ours+ 44 <br /> ow <br /> (SIGN) D. Plastic Liter _,_ E. _...---_—..-- 4. Olher <br /> NUMBER OF 9fWALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> — PRESERVATION <br /> g c s ti �6 ¢ SAMPLE <br /> 42 a1, 3f = LL F NOTES ASSIGNED CONDITION <br /> r SOME UPON <br /> 0 TE TIME SAMPLE ID r = NUMBERS RECEIPT NOTES <br /> ' ,b JO d5 <br /> • <br /> 2: C <br /> Of <br /> NOTES)MISCELLANEOUS r elinqui ed b - nature) qeqetv By: Signature) D e Time <br /> err�. i�oice �r Co�cre <br /> 749 5• S leZUS Sf Relinquished By: (Sign tune) I'd <br /> eived By:(Signature) Date Tim r <br /> �0a c�r'a�,,G'f#. <br /> k ve 13Anm yl 4'Per 114 r; Relinquished By: (Signature) Received By: (Signature) . Date Time <br /> ethod i hip a Description of Other Chains-011-Custody Dispatched By: (Signature) Data Time Received for lab By:(Signature) Date Time <br /> � /' Transport Container Transported with this <br /> Chain(by Serial No.) <br /> Send Lab Results to (Name): (Check Office Below) Verbals Requested: Yes ❑ No'O <br /> ❑ SANTA PAULA `2.2 S rSTOCKTON ❑VISALIA <br /> TEL (805) 659-0910 �211C Jl�/l ���, S82y� TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (805) 525-4172 re/K?14)972 -?941 FAX (209) 942-0423 FAX (209) 738=6273 <br /> FG1, ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0191 • FAX (209) 942-0423 <br /> 11111TE:Fk-Sj cmp, YELLOW:Pn jc t C r,% PINK:Ljk. t.x)Cop% <br />