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oAfY• SAN JOAQUIN COUNTY <br /> ,,•r o` Please send <br /> ,Iresults to: <br /> H ENVIRONMENTAL HEALTH DEPARTMENT Name: Aiii V`�"' -b <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 Email: .C< <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> CHAIN OF CUSTODY RECORD ' Ic S �� <✓ ��" <br /> 1AAAµµµ` Sample container description Required analysis <br /> L.�umber: 1 `� �.7 i�'- <br /> gL <br /> Samplers name: - e z, V c--s", p N <br /> Title: Y • � .� 6 z° m o � <br /> Unit: <br /> = z <br /> o. `w `w > o o w ? <br /> / Sa Ie address E .— Z <br /> { u m /� <br /> L c Q i o >_ N <br /> c L� C 9 2 q / <br /> Facility name: 1+nI \ �' \1 .. n o o Oj �^ LL E o <br /> Facility address: "^^[�^,��1 b L 1 NTI r"• 1�y�9t m V A w t \ <br /> Facility contact: YV1{1.ce TG(rPN"tC. �JLb ° "' ' U Y z •`. u ,«` n ° 01 a s <br /> 0 `o 6 m a a ._ Z ._ .� E w A « t J <br /> $ a « p r g z E e p v <br /> Sample Sample source Date Time w -> u r E t ' w s <br /> number Sample location description sampled sampled k m ¢ n m <br /> n',Vii �bMvti c it2b' Aa-i pw— IAL 7— 19 G 16� N x x x <br /> Lo�5t.CAI sw% 11i"ae, <br /> Name Title Date Time Remarks <br /> Relinquished by: `r Jr• r_•f RS, -7 -11 - 1 -3 <br /> Received by <br /> Relinquished by: U L !J1 "' r - <Z <br /> Received by: vRt1 'Z A�— "l L AS <br /> Relinquished by: <br /> Received by: <br /> Rev 01/23/15 CHAIN OF CUSTODY V <br /> N(TiTC , -p��', f2UV� dine fwde� r� ry II �C� tl� ��/ Su11� I rcA�vi1,�� fti�`�1 <br />