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FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> V (See Reverse for Instructions) NO. <br /> PROJECT NAME i SAMPLER SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRIN DESCRIPTION CODES - A. Ground water F. Oil <br /> PROJECT NUMBER • A. 40-ml VOA vial B. Surface water G. Waste . 1. Standard <br /> (SIGN) B. Glass Liter E. Brass Tube C. Leachale H. BlanldSpike 2. 5 Day <br /> RECORDER C. Plastic 5MrnI F.Other D. Rinseate I. Other 3. W Hour <br /> (SIGN D. Plastic Liter E. Sod/Sediment 4. Other <br /> Il <br /> NUMBER OF ANALYSIS REOUESTED <br /> CONTAINERS LABORATORY USE ONLY <br /> v <br /> AND <br /> f `-- — PRESERVATION $ g <br /> 8 LL Yi a 9 SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> $ Z BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> _1 y <br /> • 1:�L <br /> 4+ <br /> i <br /> i <br /> +4__ <br /> I � y <br /> NOTEStMISCELLANEOUS ��,�fC� In ished <br /> B/� �• , Y (Sig r Received By: (Signature) Date _lime <br /> Relinquished By: (Si na ure) Received By: (Signature) Date Time <br /> [.4$ Renuhis T: Idol J. >�• ssoc. <br /> Relinquished By: (Signature Received nature} Date Time <br /> Z L W,f r S <br /> F Method of Shipment Description of Other Chains-0f-Cus y Dispatched 8y: {Signature} to Time Received for tab 8y;(Signature) Date Time <br /> Transport Container Transported with this <br /> Chain(by Serial No.) <br /> 1 <br /> Send Lab Results to (Name): - (Check Office Betow) Verb`af equested: Yes ❑ No ❑ <br /> ❑ SANTA PAULA ` �s.. r i,.• ❑ STOCKTON El VISALIA <br /> i TEL (805) 659-0910 _ A TEL (209) 942-0181 TEL <br /> FAX (805) 525-4172 s ';" FAX (209) 942-0423 (209) 734-9473 <br /> FAX (209) 738-6273 <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br /> WHITE: Ficld Copy YELLOW:Pmjm Copp PINK:labnra[ory Copy <br /> I - <br />