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Field Sample Chain of Custody Record Kennedy/Jenks/Chilton <br /> Laboratory Division <br /> r Source of Sample (s) o `� �' '4 ``� SJ­o,1 Win Job No. <br /> n <br /> ,c L__o r~ Collector <br /> Address S Clr Affiliation <br /> Address <br /> Sac r•4 u_�0 , CA `�5 21 <br /> Phone <br /> Phone `t 1 - -cq�5- 72 Z Z <br /> Report to <br /> Sample Information (1) <br /> Lab No. Field No. Date Time Type Depth Remarks (Suspected Contaminants, Con- <br /> (Lab Use Only) (2) taine►s, Preservatives, Field COYitions, etc.) <br /> cl 0 0 51 lb /I i )5- 5(- 1 1G f i SU I"t <br /> 1601 1 <br /> �oZ �_b 0& 2- �1��11�1 <br /> o�sz0 60y V14/11 1633 1 11 �t Q " <br /> - 11025 3 b 5 '/► wli 16 3 <br /> CC 'f r ,_ <br /> OZ DIG fv '5 l`� 113B Jo f "l 1 f D r s{ <br /> �iloz 66 11rsIR� [f55 S�r� '�sS �f k - °f <br /> .i <br /> 1z o5 5,,, 1 5. 5(1 <br /> i <br /> Chain of Possession <br /> =� Relinquished by Date Time Received by(3) Date Time <br /> ( ,ignatureand affiliation) (Signature and affiliation) <br /> i Ne I ;c c4 Oar o%g- f 1j,( . k <br /> 11 72. <br /> Logged in at K1JIC 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)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 form. <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 analysis,may be determined to be"known to the State to cause cancer or reproductive toxicity;' <br />