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�0P4 `•'• '• ^ , coSAN J ® aQUuN COUNTY Name : J <br /> ' Please send results to : <br /> �l ' ��J1i <br /> ' G <br /> y .< ENVIRONMENTAL HEALTH DEPARTMENT ___ JTTTT"TT 1 bGI, P- Y� <br /> Email : mnaldu(aDsicehd.com & zbackusrasicehd com V <br /> 1868 East Hazelton Avenue, Stockton , CA 95205 - 6232 <br /> ° ' � Telephone: ( 209 ) 468- Fax <br /> 3420 : ( 209 ) 468- 3433 Web: www . sjgovorg/ehd. <br /> aCi F ORS * EHD staff to call for further instructions : Garrett Backus <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 /> FFTAnr - 1 �� cc <br /> No ooo I %owoo °� _ W w ¢ <br /> Title: / V '� 0000 <br /> z •� c Z Z Q N <br /> U �low, a o w low, w os v N <br /> C Z GO m N U <br /> Unit: �� u v c? ¢ D r :C Tool � WVI <br /> N -O N y �O N W N N .L N r14 COONI U <br /> `� 3 N f0aj `� �D N cc U <br /> Sample address c 000, o N Z n-i z U � v N N v N <br /> n ,� �^ ' o v v > z v v kD z ,1 z U w E � i° v °; <br /> Facility name: PNP VI ��VY v � S° Ln <br /> ¢ ° E N u Cr c�� v ~ v <br /> 1n' �{�J O O > H L2 N N U a- <br /> • 1 ` � I O. O O Y cOi (o U O U O F N a� N N H y <br /> Facility address: I d� r� E " aWoo, F— m U m = v m o <br /> / H O.mum, O O O N N Na a) LL N LL 1— N 1— b p IL <br /> Facility contact: �� l(/�1�--1 � ��`� .� u o ° N F o a o E j 3 i T <br /> 0 0 c a F w F _ a C J <br /> Sample y v v t c cS a v p aQ o 0 <br /> p Sample source Date Time v 0 v o J N J Q <br /> number Sample location p in F 2 W �— U v C <br /> description sampled sampled — <br /> tN ( r oll \�A calove lU U � Iq a : m (J-. 39L <br /> 'Vocla on <br /> iggDirT * rA0Ir + rck\�tf LD it liq i % o n C: 321 <br /> kAb9Dkbe0+ goo <br /> Prdln i3t n <br /> l 1 C2�1 11%jAxrbe4 0111 1 � '.S� �, (vr 3)4 CT <br /> H—H—H <br /> Name Title Date Time Remarks <br /> Relinquished by VS iI 0 i RR t <br /> Received by �; (1 N 11 0 % l G) ,gym <br /> Relinquished by: <br /> Received by: <br /> Relinquished by: <br /> Received by: <br /> Rev 02/05/2019 <br /> ru AiAi nr ri irr000Om . <br />