Laserfiche WebLink
.10 Pacific Gas and 62.1174IRav 21991 <br /> Electric Company Enuiranmental Affairs <br /> Chain of Custody Record <br /> From: Pacific Gas & Electric Company p PG&E FaciliSample Site Ship To: Lab Name: 1 <br /> Address or Location:-ZI 1 w WY_ Address: <br /> City: S�ouac-)0N . CA (zip) ki City: CA (zip) 85301 <br /> )(Contact Name/Phone No.: r►1% Phone No. '2aCA <br /> �S �d Contact Name: <br /> Turnaround Time Analysis Requested <br /> A NORMAL(10 days or less) []RUSH []OTHER,Specify <br /> Due DaR&Tlmc <br /> TELEPHONE E]FAX Give Results to: <br /> Namc PWFAX <br /> Project Nam q d o x Pro' Superviso a one No.), S �d GI <br /> . Sampled by: (Signature) C• (Print Name) ////// <br /> I <br /> Sample Nod Sam led Containers e� <br /> Equipment Serial No. Date Time Sample Type/Description No. Size Remarks <br /> °$Q! ------------------------------ -------- ------ . ----------I---- --- ----- ---- ----- ---------------------------------- <br /> -------------------------- ----------------- ----•-- <br /> -------------------------• --------- -------• ----------------------------- ------------------- ---- --------------------------- ---- ----- -------------------------------------•--- <br /> 5. ----------------------- -------- ------ ----------------------------- ------ ------ - ---------- --- -- - ---- --- --------------------------------------•- <br /> --------------------------- -------- -------- ------------------------------- -------- --------- ---- ---------- -----I---- ----- ---- ----- ------------------------------------------ <br /> ---------------------•--- -------- ------- --•-------- <br /> ------------------------- -------- ------- ----------- <br /> -- ----------------------- ------ ----- ---------------------------- ----- ------- -- ---------- ----- -- --- -•-- - ------••------------------------------- <br /> ld-------------------------- ------ ------- ---------------------------- ----- ------ - ---------- -- - --- <br /> --------------------------- -------- -------- --------------------------------- --------- --------- ---- ---------- - -- ----- ---- ----- ----------------- <br /> 1 <br /> l1. <br /> -2.------------------------ -------- ------- --------- -----------•-------- ------- -------- ---- ---------- ----- --- ----- ---- ----- <br /> ----------------------------------------- <br /> 11 <br /> y Relinquished by(Name&Dept.): X Date&Tii e � Received by(Name&Dept.): K Date&Time: Ship Via: <br /> T Relinquished by(Name&Dept.): Date&Ti e:/ Re ived bY(�at a&De t.): Date&Time: Bill of Lading/Airbill No.: <br /> AM L;PeLRelinquished by(Name&Dept.): Date&Time: Received by(Name ept.): Date&Time: <br /> SAP Accounting Data: Billing Contact: Billing Address: <br /> Notes: 1. '4mples are discarded by the laboratory 90 days after results are reported unless other arrangements are made. Distribution (See note#5) <br /> 2. :Ae a copy of this Chain of Custody Record,complete with appropriate laboratory signatures,with the test analysis results. White: Laboratory <br /> 3. The first"Relinquished by/Date"is the shipping date unless otherwise noted. Canary: Originator <br /> 4. The final PCB results will be the cumulative results added together for each PCB. Pink: Sampler <br /> 5. When this form is computer-generated,send the completed original to the laboratory,and make copies for the originator and sampler. <br /> ®PG&E November, 1998 <br />