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) <br />FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD <br />(See Reverse for Instructions) <br />LAB PROJECT <br />NO. <br /> <br />PROJECT NAME <br />PROJECT NUMBER <br />Pi , . r r '• !, I" . -'t I ‘."--4.- , SAMPLERS M. M e `I ---'' SAMPLE CONTAINER <br />DESCRIPTION <br />40-ml VOA Vial <br />Glass Liter <br />Plastic 500-ml <br />Plastic Liter <br />Brass <br />Other <br />CODES <br />Tube <br />SAMPLE DESCRIPTION <br />Ground Water <br />Surface Water <br />Leachate <br />Rinseate <br />Soil/Sediment <br />CODES <br />Oil <br />Waste <br />Blank/Spike <br />Other <br />TAT CODES <br />Standard <br />5 Day <br />60 Hour <br />Other <br />4&4B (p3INT) <br />'111--infa--6--P:= <br />RECORDER <br />(SIGN) <br />(SIGN) <br />DATE TIME SAMPLE ID Sample Container (enter code) Sample Description (enter code) NUMBER OF <br />CONTAINERS <br />AND <br />PRESERVATION Field Filtered (Check) ANALYSIS REQUESTED TAT Requested (enter code) Maximum Holding Time for Method Requested Sample Stored at 4°C (Check) No VOA Headspace (Check) NOTES <br />LABORATORY USE ONLY <br />' <br />ASSIGNED <br />BOTTLE <br />NUMBERS <br />SAMPLE <br />CONDITION <br />UPON <br />RECEIPT NOTES . <br />3 <br />D <br />cj ---- <br />4— <br />1 -1 i "_.) Vs.' c:-i tt: .0 i , ... AA 2 1 <br />----- --..e.i <br />, <br />NOTES/ MISCELLANEOUS _ i-- —'iReIin ished by: (Signature) Received By: (Signature) Date <br />''' <br />Time <br />, <br />Relinquished By: ( ignature) Received By: (Signature) '' Date Time <br />Relinquished By: (Signature) Received By: (Signature) Date Time <br />Method of Shipment Description of <br />Transport Container <br />Other Chains-Of-Custody <br />Transported with this <br />Chain (by Serial No.) <br />Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br />Send Lab Results to (Name): . (Check Office Below) Verbals Requested: Yes Li No LII <br />0 SANTA PAULA <br /> <br />0 STOCKTON <br /> Li VISALIA <br />TEL (805) 659-0910 <br /> <br />TEL (209) 942-0181 <br />TEL (209) 734-9473 <br />FAX (805) 525-4172 <br /> <br />FAX (209) 942-0423 <br /> <br />FAX (209) 738-6273 <br />FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br />WHITE: Field Cop) YELLOW: Project Cop) PINK: Laboratory Cop)