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Please send results to: <br /> SAN JOAQUIN COUNTY Name: }G., 61A17 cl-5 ot'Email! <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> IN •< <br /> \ -' 1868 East Hazelton Avenue,Stockton, CA 95205-6232 /gbackus@sjgov.org <br /> \��•rFOQas Telephone: (209) 468-3420 Fox:(209)468-3433 Web:www.sigov.org/ehd •EHDstaff tocall for further instructions: <br /> CHAIN OF CUSTODY RECORD Dl� OSOGi <br /> 1 Sample container description Required analysis <br /> TA number: 5 1—,r - Z2 ZZ E <br /> Sampler's v ° G o <br /> name: <br /> v v v <br /> �`` j. o = z = _ d <br /> Title: l7 �_^ a 5 <br /> _ N <br /> Z W <br /> Unit: MN M U <br /> Z > .Q O O Q5 0 C LD l0 N <br /> Sample address a o •• O " z ° z u w U N u aj <br /> E m > z ° Lo Z Z U ° E � N <br /> U C C Q } O G to N N U U K N H <br /> Facility name: �� m ° O $ ° w v u u u °: N <br /> C = > "O '� Q. l0 w a+ N m N <br /> ^ 'a C O Y u '� U O ef O F- N N N N <br /> L u U W u w m E a <br /> Facility address: (7.7 1, (�(k?t 1� L✓�y E a a G N N m u m a = 4 <br /> M a a O. N N LL N LL H `aJ F- a+ a <br /> �n E Y G N N Q N U H L <br /> Facility contact: / . M "^,y, ! N w o Y o m o E > 3 <br /> 0 0 — c n ~ ~w w °aE a > o 0 <br /> Sample Sample source Date Time v ;a, 3 g E L = o <br /> number Sample location description sampled sampled ~ ' ~ `n u u m cc u o, <br /> n: 4- �, 'c M; 1.f�; .i:J Lcz l� r /V X <br /> 41 X <br /> '/c•iT�'�"� <br /> Name Title Date CTime Remarks <br /> Relinquished by: ,oyr\ Alor,> <br /> Received by <br /> Relinquished by: .L (i <br /> Received by: �„y vn ✓J•z�I' j 5 / > >►¢✓• <br /> t <br /> Relinquished by:<-- i^( � 0 ( 5 ZQ !0 a '40, <br /> Received by: F�h V7'f I W 11 5)-Lo I D'.52 <br /> Rev 02/05/2019 CHAIN OF CUSTODY <br /> 7c.tr`tel r a <br />