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KENNEDY/JENKS CONSULTANTS ��f Z ❑200 New Stine Rd.,#116,Bakersfield,CA 93309 ❑6190 Neil Road,9300,Reno,NV 89602 <br /> O 670 South 338th St.,Federal Way,WA 88003 O 3336 Bradshaw Rd.,#140,Sanamartta,CA 96827 <br /> SAMPLE CHAIN-OF-CUSTODY ANAL YSIS REQUEST ❑17310 Red Hilt Ave..9220,twine,CA 82714 X303 Second St.,San Francisco,CA 94107 <br /> /� <br /> I ❑2181 East Balrshore Rd.,#200,Palo Alto,CA 94303 ❑1000 Hill Rd.,9200,Ventura,CA 93003 <br /> POSSIBLE HAZARDS: —'p1�}ry l!t%+A'_1!XQ .0"'L0'V (S} <br /> Date .�� _Iy p Vet't�J� ���7� �� ANALYS "REl2UESTED <br /> Report To av Lab Destination <br /> Source of Samples Company , D Address <br /> ` 4 <br /> Sampler Name Address Ow j <br /> Phone Phone <br /> C i <br /> Protect No Phone + _ Carrier/Way 8111 No. <br /> tu <br /> :[ll 111 COLLECTION <[2} Tura`.; 4 <br /> '1 <br /> Lati ID No Cllant.,ID No 'i Date Time type pepth Carrie Pres: ertwrw 1 <br /> 4 Corttrrtent/Condi4or18 <br /> :. ;Container type'cantaine number:eta.), ., .. <br /> G �� 11�` �[4q, Z ' 4v-m-Q ��A i <br /> 8 A -Gimcs Vo A_r <br /> K62- - Go-k& 4 Z 40- AJ V O A f <br /> 46q- CreA,3 I4zp o r <br /> 4o kJDAr <br /> 01 Write only one sample number in each space. Do rto'j—ct.^4(Y7-- nor A " 9�70e <br /> 121 Specify type of sampla(a): Water(W),Solid(SI,or Indicate type. 1r �`�r�� F;�� �1etKa�t �Z7O e• 1r i¢" teJ`Q jr TEQ+�� <br /> (31 Mark each sample which should be compoelted In Laboratory as follows; Place an'A"In box for each sample that should be compoeited into one sample;use sequential letter for additional groups. <br /> (41 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 /> ;g Print Noma ;; Sianatura CortWdnlr Date Print Name Signature....;:_. Camp DaOe' Tine_; <br /> aaey <br /> :.:. <br /> >t k 7' of j� �s`� 5 k- «►�u .� fir�� 1 b5a <br /> IMISMUSTODY2SRM OOOOea <br />