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r <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD AB PROJECT <br /> f ice' :f t <br /> NO <br /> (See Reverse for Instructions) <br /> PROJECT NAME h�;�>�s`` 1'+ r� _ SAMPLERS f t} r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 1 IPRt r DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER t s A 40 ml VOA Vial — I a Surface water G waste t Standard <br /> (SIGN) B Glass Liter E Brass Tube 1 C Leachate H BlanklSpake 2 5 Day <br /> ! rr ( L— C Plastic 506 mil F Other D-Rinseate I Other 3 60 Hour <br /> RECORDER �'` D Plastic Liter E Soil/Sediment 4 Other <br /> {SIGN) ----- <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND m n n ,� <br /> m a— PRESERVATION <br /> m^ <br /> �$ e m o a m SAMPLE <br /> m °mTT <br /> ¢m E~ d`—' a0' NOTES ASSIGNED CONDITION <br /> Em EmLLV <= °V BOTTLE UPON <br /> DATE TIME SAMPLE ID, r z NUMBERS RECEIPT NOTES <br /> 1 <br /> 1i `C) �� .r lr rt if r � � "" F � ✓ 1 r <br /> "-6)' <br /> NOTES I ISCELLANEOUS / ! ter rd}r t r fir ^� Iin gnature) Recce ed By (Signature) to Time <br /> Jb i,46r <br /> ,;! Relinquished By (Signature) ve6-BHstgnature) Date Time <br /> Ke), <br /> }}�� I / + ,> Relinquished By (Signature) Received By (Signature) Date Time <br /> met';' <br /> � ei �,.� <br /> N �r <br /> Method of Shipment Description of Other Chains-Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this , <br /> Chain (by Serial No), <br /> t <br /> Send Lab Results to (Name) t: r C (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ SANTA PAULA V STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 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 (249) 942-0423 <br /> w HITS Fi,Id Cop. YELLOW Pmleci Cnp, P114K Latxirawo Cup. <br />