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Field Sample Chain of Custoe Record <br />Source of Sample (s) Stoc 1(40A UV' -erg S`kft l <br />Address Sfoclt Uy-, <br />Phone <br />Reportto Noel Acrncr <br />Sample Information (1) <br />KennedyJenks,'Chilton <br />'` Laboratory Division <br />b Job No. (510?10 02- <br />Collector <br />2Collector Jo RKfStll <br />Affiliation ��"`� c�°t"'� �°� mer r•�� , <br />Address 37S -()A -4"e-^ IB W , 5,4z4e � <br />5ctcrwrAoJ CA 15S21 <br />Phone 116- k$S- 72 2 Z <br />Lab No. Field No. <br />Date <br />Time <br />Type <br />Depth <br />Remarks (Suspected Contaminants, Con - <br />(Lab Use Only) <br />(2) <br />tainers, Preservatives, Field Conditions, etc.) <br />01160 <br />//h1140 <br />10-zq <br />Soil <br />13-04Io,,,k <br />#1 (10t0001al dtese' SW corn <br />- 017 <br />"Al NO <br />/04 Z <br />Soi <br />12.5-fk <br />Ta..k #l1 - NW% cor%tr <br />per— <br />'Ih1110 <br />11D6 <br />til <br />yf+ <br />Rcwofcr1— P>,r,g *I <br />_ OI <br />°lulyo <br />1116 <br />So;1 <br />3.5F1 <br />Rw e+e c;ll- 4L -Z <br />02-0 <br />1141140 <br />I1 Z 3 <br />5,.1 <br />y fF <br />kov dt Till- P Ptr-ter 3 <br />bz— <br />II/i1110 <br />1130 <br />5orl <br />N R <br />Re oie 01- t�,y *1 <br />— OZz <br />it/zllyo <br />1131 <br />Soil <br />y. 5514 <br />p- '^ *5 <br />023 <br />N/21 /10 <br />)115 <br />Sot, <br />q fi• <br />(f��c (,-11- <br />r\,+* lilt— <br />— d2� <br />11��i190 <br />/ISy <br />soil <br />y f+ <br />kande SII - P' inn It -7 <br />Chain of Possession <br />Relinquished by <br />Date <br />Time <br />Received by (3) <br />Date Time <br />.. (Signature and affiliation) <br />(Signature and affiliation) <br />1. <br />2. <br />Logged in at K/J/C by <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) e.g. water, sludge, soil, etc. <br />(3) k any samples are not intact at lime of transfer, please describe on the back d 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 />.-- , rd -... c,,- n -L t,. .+T.. -c F,'---,- ­• F^ "10^t r..., .- r.I .. <br />