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Relinquished by: <br />Received by: <br />Relinquished by: <br />Received by: <br />Rev 02/0512019 <br />Relinquished by: LA4 dicA ICia-d <br />Received by S <br />tr <br /> <br />Yess ttA- Gisru44ti. <br />PoS44.1011 <br />-',#/at/ L-hbs k'i4, ‘A. <br />GI* Teal <br />TZEo30‘ <br />SAN JOAQUIN COUNTY <br />Factfic ico Cold invoice_ ENVIRONMENTAL HEALTH DEPARTMENT <br />CrAui refer* fo 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />60, Arialettal Latoaphone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />CHAIN OF CUSTODY RECORD <br />Please send results to: <br /> <br />14, V.: II KA •—) <br /> <br />Name: r---Lv, • ILA toa <br />Email: emanzoesmov.om & RbaCkLISPSfil0V.QM <br />*EHD staff to call for further instructions: Garrett Backus <br />(209) 468-2986, Elena Memo (209)953-7699, Muniappa <br />Naldu (209) 468-3439 <br />TA number: <br />name: <br />Title: <br />Unit: <br />' '-1 — i Ct —1 5 '2- Cf Method of sampling: Composite (C) Grab (G) 3'621 Size of sample container (include units) rt o descri tion , Required analysis Type of sample container: Glass (6) Plastic (P) Metal tube (MT) VOA (V) Evidence tape: Yes (Y) No (N) Transported in iced cooler: Yes (Y) No (N) TTLC, Title 22 California Code of Regulations (CCR) 66261141a1(21(Al TCLP„ Title 22 CCR 66261.24(a)(1)(0), if necessary MALL END STAFF BEFORE RUNNING FOR FURTHER INSTRUCTIONS I STLC, Title 22 CCR 66261.24(a)(2)(A), if necessary (CALL END STAFF BEFORE RUNNING FOR FURTHER INSTRUCTIONS) ]Cam 17 metals, Title 22 CCR 66261.24(a)(2)(A) Chrome VI, Title 22 CCR 66261.24(a)(2)(A) "Fine powder" measurement (Particle size <100pm In diameterl Ignitability, Title 22 CCR 66261.21 Reactivity, Title 22 CCR 66261.23 Corrosivity (pH), Title 22 CCR 66261.22 96-hour fish bioassay, Title 22 CCR 66261.24(a)(6) Sampler's <br />SR. t()•--CA S <br />lir... <br />Facility name: <br />Facility address: <br />Facility contact <br />Sample address <br />...)(2-. Sitytob-k- ct, <br />ti k'k S Mc,14y1k.td Kw. <br />VI2q.— itylgti.ek_ <br />Sample <br />number <br />Sample source Sample location description <br />Date <br />sampled <br />Time <br />sampled <br />& ‘‘ — a <br />Wiecst Ci -C <br />SOI 1 5131aa ciDarn (7- Si). <br />C7e (7 \)( / <br />'4O ..... Temp C <br />Name Title Date Time Remarks <br /> <br />6141.Md- a.10-(Ain <br />5///'7 /;:/km <br /> L-\16SIY`r\ <br />5N7 /- /Oct <br />CHAIN OF CUSTODY <br />9/15