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Field Sample Chain of Cu s "' Record ( Kennedy/Jenks/Chilton <br /> Laboratory Division <br /> Source of Sample(s) �fo c k el u�'` `e� 5J111111 L8 Job No. 00310 02- <br /> 4,475c <br /> Z404;5c H'*1 sc.�fsc� Collector (v nKSSC 11 <br /> Address _ SfoU(+Oy' Affiliation �'^^`c� -- --�•err.er��►�< < - <br /> dress 37S-0 k -k6"_e\ B14 , Su z l e A <br /> Phone _5gcrckr *~+or C q5$ Z► _ <br /> Reportto No eli L,er r-,-cr Phone 11 — qES— 7.2 Z Z- -- <br /> Sample Information (1) <br /> Lab No. Field No. Date Time Type Depth Remarks (Suspected Contaminants, Con- <br /> (Lab Use Only) ( ) tainers, Preservatives, Field Conditions, etc.) <br /> 01t'0 /1/21 110 10 zq 50;1 13.0 f+ 7""1 #1 00'am 4( J;cs SW Cory. <br /> 017 'flat ho . /047 S # 1z-s{+ TaKk *ill — Al V%/ <br /> -0/8 t1/z114c 0, <br /> - C.�1 t'�z�1ya �� 1� s�;f 3_S� 1Lar^a#e �:�!— 1 �Qir►y �Z -- <br /> 02-0 141110 I1 Z 3 5t 4 fF ka,-,o4e <br /> bZ I a/zI No 1130 5orl Re,,,fe ';1I- �;p�►•k # <br /> 042, '�/r11�o Ii' 3� Sr,j q. 5ff �o{e ;11- <br /> 021-3it/z�1yo 11N5 S �1 y f� R +e1�- _ <br /> i n � 7 <br /> Chain of Possession <br /> Relinquished by Date Time Received by(3) Date Time <br /> (Signature and affiliation) Signature and affiliation) <br /> 1. <br /> 2. <br /> Logged in at WIC by <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)ag water,sludge,soil,etc. <br /> (3)If any samples are not intact at time of transfer,please describe on the back of this forML <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 anatysis,may be determined to be"known to the State to cause cancer or reproductive toxicity." <br />