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SAN JOAQUIN COUNTY <br /> Please send results to : <br /> y. ENVIRONMENTAL HEALTH DEPARTMENT <br /> Name : �� I:hs S' Gal4 <br /> 1868 East Hazelton Avenue, Stockton , CA 95205 - 6232 <br /> Telephone: (209 ) 468 -3420 Fax: ( 209 ) 468 - 3433 Web: www . sjgov . org/ehd Email �'�= ,�(cc � � <br /> CHAIN OF CUSTODY RECORD <br /> rl Sample container description Required analysis <br /> fat <br /> RO number: l J �/ 9 tl-; � E <br /> CL- <br /> Sampler' s name: ( w ovaj <br /> i <br /> V Q' <br /> Title: Lf' ' d < 1 c� a ° m z v <br /> Unit: Loot v > <br /> N v V) a <br /> ° ru <br /> Sample address o _ v� m <br /> ° V a`) > z ...]e <br /> n U C ° W R <br /> Facility name : I""'} )�'�.�' .t �a— ►J4 � xLl / � yt�%rte V I �'1Kz_� ago 3 _o <br /> d Q o °V y u � � aj <br /> Z E M <br /> r_ LL <br /> Facilityaddress : E v ~ .� M M ° <br /> N C E q u ti U aJ 'O <br /> Facility contact: o z C: ° v o = y <br /> Sample Sample source Date Time v a a v z ° <br /> number Sample location description sampled sampled 2 N ~ LU <br /> ~ ~ CC UL ° O1 <br /> i,. ;, r eel Y,4 -CA Z2DA Gr 16 >; <br /> i �}� ✓ - 2 <br /> LACf ,wlCL <br /> Name Title Date Time Remarks <br /> Relinquished by: ti � s �r r l� C •— r' �+;, anV ' a� . � 4cao v .. <br /> —� I <br /> Received by SrJs >' y�thr ( G�< < 7tS r! lCf % � (D : 4 of 1� � G � *Vcd, Ct l05< !� S . 7Jc . �-�J >7 5 <br /> Relinquished by: e" r Rv✓4016 Q PSg� //moi / � lSpm rel ;hyu ,'shee4 188L= �,? � 1toy, �Shtk1A <br /> Received by: C7 erk; Gv <br /> Relinquished by: Sr -�� 's ZC r ' p 6::) cl—� <br /> Received by: , � �%1 I /E �^2 i�-P C, g' UCS <br /> Rev 01/23/15 CHAIN OF CUSTODY <br />