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Field Sample Chain of Cus ` Record Kennedy/Jenks/Chilton <br /> .01 X a Laboratory Division <br /> Source of Sample (s) d k Sty S �rJob No. d() S 2 0 0 Z <br /> 5 -oddan 51-kool Ur L,L Collector 301,.,. r ,If e jl <br /> Address _ S--oJ,,fRn C,!! 4 _ Affiliation N W c l( 01.E d L,ern e r _J, 1:►•% t <br /> Address 3 S� urv� 1B I uJ. g <br /> Phone Sa c ra w.RnAO , C-9 '75821 <br /> Reportto Nae Phone 511b— qSS— 7222- <br /> Sample Information (1) <br /> Lab No. Field No. Date Time Tye Depth Remarks (Suspected Contaminants, Con- <br /> 9. <br /> (Lab Use Only) ( ) tainers, Preservatives, Field Conditions, etc.) <br /> T4..k 41ZC 500 fe J as <br /> 013 V11/10 152-77 ,l �.sf+ _ ) <br /> Di )i��q Its lS3 Sw, t2.5 f+ To--JkitI (10,000 �,� C"r,".IV <br /> . <br /> 0 )5 It/19 /q0 154g 2.574 T--,,,,,k v — � 0t`v►ey� <br /> Chain of Possession <br /> Relinquished by Date Time Received by(3) Date Time <br /> (Signature and affiliation) / Signature and affiliation) <br /> P <br /> 2. <br /> Logged in at KWIC by <br /> (t)A separate Laboratory Analysis Request Form is to be filled out by the collector and gi ten to the laboratory when samples are delivered. <br /> (2)e.g.water,sludge,sal,etc. <br /> (3)If any samples are not intact at time of transfer,please describe on the back of this forin. <br /> Each batch of to 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 />