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Field Sample Chain of CusP-w Record Kennedy/Jenks/Chilton <br /> Laboratory Division <br /> H Q <br /> Source of Sample (s) 5 ^ u"" �` Job No. 00U ADO l <br /> 'Ji5' ;t� rdt5o� r�� SG4� _ Collector <br /> Address .— <br /> S�c.� (filiation f f e �w.;Ck !j L orY,Q,- <br /> Address 3750 A b 8 I vd � 51�7�e A <br /> Phone Sac <br /> Report to - <br /> /�b� ,�.e�- hone _ 916— qgT 7ZZZ <br /> �--- - - <br /> Sample Information (1) <br /> Lab No. Field No. Date Time Ty pe Depth Remarks (Suspected Contaminants, Con- <br /> (Lab <br /> orn(Lab Use Only) cE r tainers, Pre+serrvatives, Field Conditions,etc.) <br /> 025 1L/6jjQ 1351 J �� C1 Taj .*J ilo�o0OsR��ieSe�, ce4z?- <br /> r <br /> i <br /> Chain of Possession <br /> Relinquished by Date Time Received by(3) Date Time <br /> (Si nature and affiliation) (Signature and affiliation) <br /> 2. <br /> Logged in at KIJIC by <br /> (1)A separate laboratory Analysis Bequest Form is to be filled out by the collector and g iven 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 fo m. <br /> Each batch of 10 or fewer samples of each matrix type(soil,water,etc.)must include en ugh of one sample for triplicate analysis. <br /> WARNING These samples contain unknown chemicals which,upon analysis.ma be d termined to be"known to the State to cause cancer or reproductive toxicity' <br /> ._._. <br />