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Field Sample Chain of CusW Record <br />Source of Sample (s) EdI 50 N 4i` S1 r <br />Sf-adkfr. (t. S�Roof n�fr;�t <br />Address S�oc �� � CA, <br />Phone / <br />Report to Noel Ler rher // TO(,. 9!! i� <br />Sample Information (1) <br />Kennedy/Jenks/Chikon <br />Laboratory Division <br />l"i'dtl¢ Job No. 00MOz- <br />Collector So (� P k r5 e h <br />Affiliation Hr �H c1� vj �err%er ,riNC <br />Address 3750 AKbNcr 51A �S,47 ie A <br />15821 <br />Phone jj(- N85-- 7222 <br />Lab No. Field No. <br />Date <br />Time <br />Type <br />Depth <br />(Lab Use Only) <br />(2) <br />013 <br />))/11/10 <br />/527 <br />504 <br />7,SFf <br />01 q <br />)llicjho <br />1538 <br />5., <br />12.54 <br />O )5 <br />11/19/5o <br />154V <br />-C,, -I <br />)2Sf} <br />Cflain of Possession <br />Relinquished by Date <br />(Signature and affiliation) <br />2. <br />Logged in at K/J1C by <br />Remarks (Suspected Contaminants, Con <br />tainers, Preservatives, Field Conditions, etc) <br />T'-Ik wZ( 500 0 le4dQJ qas) <br />Ta- kk)()0,000,_ i") -SW cor,,,, <br />T.. It a 1 — S E Corner <br />Time Received by (3) Date Time <br />(Signature and affiliation) <br />(1) A separate Laboratory Analysis Request Form is to be filled out by the collector and given to the laboratory when samples are delivered. <br />(2) egwater, sludge, ad]. etc. <br />(3)"any samples are rot intact at time of transfer, please describe on the back of this form. <br />Each batch of 10 or fewer samples of each matrix type (soil, water, etc.) must include enough of one sample for triplicate analysis. <br />WARNING These samples contain unknown chemicals which, upon analysis, may be determined to be "known to the State to cause cancer or reproductive toxicity" <br />