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�Aquly' SAN.JOA UIN COUNTY <br /> h _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ,�� VV�GUU�1l1 <br /> % <br /> 1868 East Hazelton Aven je,Stockton, CA 95205-6232 Name: <br /> lJ.VeI ,'�eh�. <br /> • �`' :.„:,, �•: Telephone:(209)468-3420 Fax:(2(9)468-3433 Web:wwwsjgov.org/ehd Email: <br /> FORS <br /> Fax: <br /> CHAIN OFC STODY RECORD <br /> Sample c ntainer description Required analysis <br /> RO number: E <br /> o <br /> Sampler's name: Ll t) t� v •� <br /> Title: rl'f'. 1t�1`Il t� i S ° m w .• _ <br /> z o_ — <br /> Unit: w = L a b E <br /> z r o <br /> Sample address n .`� o w ? a <br /> _ o `m � 2, z o c y <br /> V a s N <br /> Facility name: Ili Sl7 � . rr'G[—tIV1Q m . 0 .° �F- <br /> Y ( G+w o C� �Cti�1 hi <br /> Facili address: N — n ,5 '^ K _ i a 4 <br /> ((t1 / E m O1 N <br /> Facility contact: 1�A l._ ” r Y ° m r v C m �^ c E <br /> SampleSample source Date Time a a > a :� A `✓ E ° = v <br /> number Sample location description sampled sampled u <br /> fe"aN <br /> JL 116 frA <br /> '�Sl %&LRA `f6 <br /> Na e C TTi�ttll�J, Date /\ Time / ^ Remarks <br /> Relinquished by: A1>1 Su �Y 1 �� l"-' WS <br /> � ' <br /> Received by <br /> Relinquished by: __TT <br /> Received by: <br /> Relinquished by: <br /> Received by: <br /> Rev 01/23/15 CHAIN OF CUSTODY <br />