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a SAN JOAQUIN COUNTY HyL I <br /> < ENVIRONMENTAL HEALTH DEPARTMENT Please send results to: <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 Name: U eo- 7 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd Email: elfin 6 r W✓n <br /> CHAIN OF CUSTODY RECORD S <br /> Fax: 34 <br /> 'r• j r, ( Sample container descnptian Required analysis <br /> RO number: 1�"1�l �'�'Q rj <br /> E <br /> a <br /> Samplers name: -ZV,Q <br /> Title: z w <br /> ? o <br /> Z v <br /> Unit: <br /> j� <br /> 0Sample <br /> = i <br /> Sample address c 0 <br /> = E <br /> E - o o c w` > z E <br /> Facility name: <br /> m <br /> � r <br /> Q.bo Y) p <br /> Facility address: Aj 6• k` b �cA � " ILS 2 <br /> Facilitycntact: (ucc <br /> p E E o m 'u ° u u a ' r <br /> v 9 w o c c E > 3 d Z' <br /> Samplet `o o — n ti w o q a <br /> number Sample location Sample source Date Time v „ r y W m � E e r <br /> description sampled sampled '^ �' f �= r r- N <br /> o n m <br /> ( - A 6Qw •I Er 4 1( X X X X <br /> ---------------------- <br /> ------------ <br /> Name Title Date <br /> Time Remarks <br /> Relinquished by: <br /> Received by , �l �1V,-A—.---?QL_�1m�I'—_It 3✓WZ <br /> Relinquished by: /J.,./I..- IZ Z4 � <br /> Received by: LLAA77PP4>S411a�1� _y•5y __ <br /> Relinquished by: <br /> Received by: <br /> Rev 06/05/13 <br /> CHAIN OF CUSTODY <br />