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i <br /> 'oPqu,N c Please send results to: <br /> o SAN JOAQUIN COUNTY <br /> _ •'\� Name: � U1,2 <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> Email: k5jeepdcam$ <br /> i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Fax: <br /> P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> �/FORS •EHD staff to call for further instructions:Garrett Backus <br /> 6RMichelle Henry(209)468-3453,Kasey Foley <br /> CHAIN OF CUSTODY RECORD (209)468-345 <br /> Sample container description Required analysis <br /> TA number: I E <br /> i <br /> 0 <br /> Sampler's name: cl, v <br /> rte ] w � <br /> Title: o m Z <br /> Z v <br /> _ LL O Qj <br /> Unit: Q) > ¢ C t <br /> N V h N <br /> ° v o m <br /> Sample address J z v <br /> E z `m — E <br /> /��� n r �` u c m ¢ r ° Ux <br /> Facility name: t" (,!r LvrI CVS �, fl�y,ll, om y o <br /> E o ° > > v r v N <br /> Facility address: + `G �.'�l ���f r n� �R� t.�^^f'( A- �5a)� v a v S D m �°— <br /> n. cLO <br /> -° v <br /> �11�, E v r' v u <br /> Facility contact: J�'1 �C �/ �L1y\ �° u o z c E v o <br /> r o ° a°i wz w `� E aE o <br /> Sample Sample source Date Time m ° a v -2 a z E ° E r <br /> Sample location , w F F N u u LL c oo aUS <br /> number description sampled sampled — <br /> Name Title Date Time <br /> � Remarks 1 <br /> Relinquished by: cr fG*<'�' Cr'l� /C-C Tri j 1 1i i�j / • /`y �� ' I I <br /> r_ 5���^�t2s ��✓ 1 . <br /> Received by <br /> Relinquished by: �I S WR ,UV c J <br /> Received by: JF�I5�r 12-11-I(� I ,U(2#,,- <br /> t 1 ++ <br /> Relinquished by: >tjY/� �Lrlet �t )1 � I S <br /> Received by: <br /> Rev 07/31/15 Temp 3-L C LASER #1 <br /> CHAIN OF CUSTODY <br />