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o qu � ry o a Please send results to : <br /> TSVI <br /> o SAN JOAQUIN COUNTY <br /> y Name: ( /l <br /> 1< ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton , CA 95205- 6232 Email : mnaidut@slcehd.com & ebackuslasicehd.com <br /> Telephone: ( 209 ) 468-3420 Fax: ( 209 ) 468 -3433 Web : www . sigov . org/ehd * EHD staff to call for further instructions: Garrett Backus <br /> OR � <br /> (209) 468-2986, Michelle Henry (209) 468-3453, Kasey Foley <br /> CHAIN OF CUSTODY RECORD (209) 468-3451' <br /> Sample container description Required analysis <br /> TA number: X1� z z E <br /> Samplers cu N ° M o D <br /> name : 1 (? <br /> v <br /> d p N N UN N N <br /> z c N <br /> Title: z c <br /> y N o N w = w f0 H N lD <br /> (DN,. y N N <br /> 0 m H H N (0 U H lD <br /> UD <br /> Unit: U v r N LL Q LL LID v ti N <br /> -p ^ 0 V N N V N N U <br /> in O (0 N N N O O ko H N to N <br /> Sample address 0- c (9 o } O N 0 N ; oc v N U N <br /> 1 c0) OJ N > Z °' � lD Z N Z U '° E l0 � N -• <br /> C O C N Z lD Z N 4' 0 N H <br /> ' p Q Y U N ' U U ai <br /> Facility name : N om o $ v U u <br /> 77 <br /> Facility address: 1 v o a 5 N N N m v m = v = ° <br /> Facility contact: L I�'f/ t� V I 1 Qif �J� liqft �' v ° �'4. N 01 ~ ~ <br /> 0a ^ t a v E > ' > Y <br /> 0 0 � c o- N F E n > <br /> Sample Sample location Sample source Date Time a) Q v S S L 0 o <br /> number p description sampled sampled ~ F N - u u _ nn o U D <br /> reo <br /> Don <br /> Name Title Date I � Time /y� Remarks <br /> Relinquished by: `� ��� V q i` q lJ I Do I " / <br /> Received b 4 jo <br /> Relinquished by: <br /> Received by: <br /> Relinquished by: <br /> Received by: <br /> Rev 02/05/2019 CHAIN OF CUSTODY <br />