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Field IF ample Chain of Custoe Record <br />Source of Sample (s) 5f -k- k, u— �- 4 5&eO1 <br />Nslt;ct- � i5:dr5o, <br />Address 54jk4c',", <br />Phone <br />Report to /V a'F t Ler r e, <br />Sample Information (1) <br />Lab No. Field No. Date Time <br />(lab Use On'y) <br />02.5 1716YIo 1351 <br />Chain of Possession <br />Relinquished by <br />(Signature and <br />0affiliation) <br />� <br />{� L r <br />2. <br />Logged in at K/J/C by <br />Date Time <br />NO,. 1700 <br />N Lr <br />WWV Job No. <br />e Kennedy,-Jenks,/Chilton <br />Laboratory Division <br />00$ %0o Z <br />Collector Job-,, RU5e. <br />Affiliation lyd `Ck C4 L ar,ar- ,1kc <br />Address 375o A kb '�rr, BW , 54 +t A <br />Sar_. -6L . & -o, CA `1 SSZI <br />Phone 91"l 4155'-- 7ZZZ <br />Type Depth Remarks (Suspected Contaminants, Con - <br />(2) tainers, Preservatives, Field Conditions, etc.) <br />S4 )q(} Te"I *i (10.i a'11d;rfel) ce Jer <br />o, <br />Received by (3) Date Time <br />(Signature and affiliation) <br />R aI,�.A,.. I ad /0 61-!!X <br />dfl�, t -V 1,/J/c <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) If any samples are not 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 />