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m m <br /> SAMPLE CHAINWF CUSTODY RECORD <br /> DEL-TECH GEOTECHNICAL. SUPPORT (PL1`1ASis PRINT) Lab. Analysis by <br /> 10624 OLIVE AVE. OAKDALE, CALIFORNIA 95361 LAB. INVOICE TO : 1W)K W-.VTF _ <br /> OFFICE (209) 847-8757 <br /> FAX (209) 847-7744 RECORD ^-OF PH. # <br /> CLIENT / CONSULTANT: - - T a P.O.# INVOICE# <br /> �`� ANALYSIS REQUESTED SITE SAMPLE MAI' <br /> PROJECdI\1 <br /> T I SITE NAME: �) `._ f ITEMIZED AND CHECKED BELOW) i ��ryy <br /> cn <br /> W ZZ to U Y PA vA <br /> car j J <br /> c:' U <br /> STREET: ' l- t. {,lt� CITY: � �- f �a'� STATE: �� I � o nW a � � � <br /> <n 2 w U CD <br /> ff Q eT O2 W <br /> L)I'Ev <br /> cm <br /> THIP VIA: ( � v o o= z mSAMPLER: sIGNATURR) AYBILL# Q�'1�r— o 3 � � <br /> cx i co <br /> lii x w '7 <br /> NUMBER TYPE SAhfTI E c� x a o c5 v <br /> SAMPLE LOCATION DATE TIME x z a a <br /> (IDENTIFICATION) MTHJDAYnX SOUR/MIN. OF f CRA 8 OR hfATRM a• O= ~ o N N <br /> aoxrArN&Rs mMIVSITE) �- � I- oo co 00 0o F REMARKS/* SPECIAL INSTRUCTIONS BELOW <br /> 5.) � lt►sT �. 1 l <br /> 7.) C1v� <br /> lit too <br /> IO. <br /> SAAIPUINTEGRITI'ICONDITION47'URNAROUNI)TIME •• <br /> /0 i RECEIVE[)COlLD A INTACT / vv,; �rf No <br /> J]/l .�. <br /> RE NQU I'll )ATE f TMIF: "! � RECEIVED R\':���r.n.T.�.., IATF./TIME: FKFSFR�'ATIYEi4 USED ..ti'ES � � No � ) <br /> - CUST06Y SEANS,INTACT f YEC No ( } NIA {� <br /> AIR R mns,.S IN V.O.A.'S f YES } NO LINE R <br /> RELINQUISHED BY:OWN-UM )ATE TIME: RE(-EIVFD R}':tSir.H"To.r, )ATF./TIME: <br /> TURN A ROUND TIME, CIIECAONE' <br /> RELINQUISIII•a)BY: )ATEf LIME: ECE '13) B]'1 ABORAITORK,HOTT n•MH.knc:rm I-S. LATV 1-1.1 ME: -'a- IIO)I�R ( � lR-11O UR { � . 'DAV 10.11 <br /> NOTE: LARORATORY SAMPLE ARCHIVING WILL BE M DAYS FROM THE DATE SAMPLE WAS COLLECTED,UNLESS OTHER ARRAINGF.AIENTS ARE MADEL <br /> PLEASE RETURN DEL-TECH'S ICE CHEST AND BLUE ICE AS SOON AS POSSIBLE. THANK YOU DEL-TECH FORM C.O.C. <br /> Pink - Field Cory / White & Yellow - To Laboratory wish Samples / Yellow - RcIt rn to Client with Results <br />