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C C L L C il <br /> 1 U 4 ter <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD 1,3 `{ a � LAB PROJECT <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME T t� ' �/�'�l P 04—6-!;: SAMPLE4184' 14r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> ( ) DESCRIPTION CODES A. Ground Water Y. oil <br /> PROJECT NUMBER -A:',40.m1 VOA vial B. Surface Water G. Waste t. Standard <br /> SIGN) B.K&ass Liter E. Brass Tube C. Leachate H. Blank/Spike 2. 5 Day <br /> RECORDER 4 C. Plastic 500-m1 F.Other D. Rinseate I. Other 3. 60 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF 't71NALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS o <br /> AND <br /> PRESERVOON d -�,- -6 <br /> E¢ t=t SAMPLE <br /> m Qd �$ a oo NOTES ASSIGNED CONDITION <br /> Em E- a = LL I > BOTTLE UPON <br /> DATE TIME SAMPLE ID N = N Z NUMBERS RECEIPT NOTES <br /> ! Z aro } EUJALL N6;2-174 I I2 <br /> 340 li6cv.4cC cAsr eA Ci suA 0 G �+Ua <br /> 134; UJ/¢GL SOv <br /> t3iT <br /> 330 oM rrAST <br /> 133r FortO C-7r <br /> 41Y 1L 00MP -&)04?T4+ <br /> 141-7 A- COW ? OPLE <br /> Zo /L 02AA P Sb(i' <br /> NOTES/MISCELLANEOUS r-s � � �'p S y f p� rdyy� R i quish : (Signature) Re v y: ignature) D to Time <br /> e nquished By: (Signature) Received By: (Signa ure) Date Time <br /> S ZUS Relinquished By: (Signature) Received By: (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> (btnd � Transport Container Transported with this <br /> Chain (by Serial No.) <br /> Send Lab Results to (Name): U U r So r ZZ 7-0° . 0)5 �>( �' eck Office Below) Verbals Requested: Yes No ❑ <br /> ❑ SANTA PAULA Ai� r�70)5772 ❑ STOCKTON ❑VISALIA <br /> TEL (805) 659-091Q,J2AV ,P /' 972 TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (805) 525-4172 FAX (209) 942=0423 FAX (209) 738-6273 <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 ..r <br /> WHITE:Field.Copy- YELLOW:Project Copy PINK:Laboratory Copy <br /> w.r.. <br />