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Field Sample Chain of CuRecord A- � -D If % "-% b AC kennedy/Jenks/Chikon <br /><6yq 364 R 3, "*09 Laboratory Division <br />Source of Sample (s) (-0.N - TW 1(,N <br />Address -LGdcOy.� • �f�0`� rcn <br />Phone <br />Report to \2,e_\\4R \k <br />Sample Information (1) <br />Lab No. Field No. Date Time <br />(Lab Use Only) <br />H q 3,P) /� fi <br />kKs 3�s A <br />Chain of Possession <br />2. <br />K/J/C Job No.o L jMZ�s�-)C� <br />Collector �z��ti \ \LtL\Am\e \I <br />Affiliation <br />Address33��4 <br />Phone C\\u- "tea <br />Type <br />(2) <br />-\ 4-\0,,-17v0 <br />Depth <br />-Z 4-QC\-qo 5 ", <br />-3 4-:4\-C G'-�q' <br />Relinquished by Date Time <br />(Signature and affiliation) <br />Logged in at K/J/C by <br />Remarks (Suspected Contaminants, Con- <br />tainers `` Preservatives. Field Conditions, etc.) <br />�1Pt\-\i) <br />=Klw� _ i;- Y -� $, 1;�_:- l <br />7EPH <br />Received by (3) <br />(Signature and afffiliation <br />Date Time <br />A/mac A 3a <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 />under the California Safe Drinlung Water and Toxics Enforcement Pct of 1966 (Proposition 65). Lab -6 ILABI <br />Note: Top (Original) copy to laboratory with samples. Rev. 12/66 <br />