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c SANJOAQUINCOUNTY i Please send results to: <br /> / o\ Name:'✓Qpoe) C ki Ito C 1-)P6)LI,4 7 <br /> y <� ENVIRONMENTAL HEALTH DEPARTMENT Email: tad air E 013/kku5� >� <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Y <br /> P <br /> 4�ir:OR \ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd Fax: <br /> c� *EHD staff to call for further instructions:Garrett Backus <br /> F�Ki��� (209)468-2986,Michelle Henry(209)468-3463,Kasey Foley <br /> CHAIN OF CUSTODY RECORD <br /> (209)468-3451* <br /> Sample container description I Required analysis <br /> TA number: 1� 7 y`,`7 E <br /> a <br /> 0 <br /> c� = s <br /> Sampler's name: Gt�-'\ L-7Ci; �z"tll V <br /> L Y <br /> Title: C r I — m o m Z <br /> L�n •� o. z LL � <br /> Unit: ���1 /7 < <br /> v <br /> O V Z } = t; <br /> Sample address CLE _> o - w z w <br /> O CZ '01 Q u <br /> a0 } O U 2 7 <br /> Facility name: L;,L(,; * <br /> .,�7/ / a o o > d �LL E <br /> Facility address: �[,C (/t/ tkay Kt)7 jk,4- f 1 C(5�� // E ° T g u G z E <br /> D. m <br /> E E v a U O u v L <br /> Facility contact: m „ c l0 c E - <br /> O N <br /> 0 o O " C M w Z — ti N o. E a <br /> Sample Sample source Date Time a, H a y J J Z E ° E �, o <br /> number Sample location description sampled sampled 2 ' ~ ' ~ � `LA U U LL `- ° n oO <br /> fiehL eek :,M I iru I 32,.� 67 N X X <br /> -- o ( <br /> /!ib•G ,}L �'� :-� (�tc'L�SC �Gi �-'�/ n ��, ✓1N •Sct N <br /> ( rr M If <br /> / ., <br /> L c. L L <br /> a z <br /> Name Title Date Time <br /> ` (� Remarks <br /> `/ <br /> Relinquished by: ~w ,C S /LC /Y S l r I �1 " <br /> 1 �-,_._ � J Vis.:,-� �'�•, <br /> Received by o 9 L !/}(., <br /> Relinquished b <br /> Received by: �.! f �TI 1cc <br /> Relinquished by: — eMD </- r LASER <br /> A��� � <br /> Received by: <br /> Rev 07/31/15 <br /> CHAIN OF CUSTODY <br />