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• FGL ENVIRONMENTAL C N-OF-CUSTODY RECORD PROJECT <br /> (See Reverse foTr Instructions <br /> ��yyam^ p ) NO&_. <br /> PROJECT NAME IJDl.VGaC�S`-BAMPLERS # � SAMPLE CONTAINER+ SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRIN DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBE�11�.�R <br /> I'+P/ A. 40-ml VOA Vial S. Surface water G. Waste 1.-S <br /> (SIGN) B. Glass Liter Brass Tube C. Leachate H. BlanklSpike 2. 5 Day <br /> DER C. Plastic 500-ml F.Other D <br /> (SIGN) D. Plastic Liter I. Other 3. 60 Hour <br /> E. SoillSediment 4. Other <br /> NUMBER OF ArXLysis REQUESTED LABORATORY USE'ONLY <br /> CONTAINERS <br /> i• _ a AND m Y <br /> no am PRESERVATION o^ <br /> SAMPLE <br /> E a"<v NOTES ASSIGNED CONDITION <br /> E o <br /> DBOTTLE UPON <br /> F TE TIME. SAMPLE ID N y = NUMBERS RECEIPT NOTES <br /> 4 <br /> t� <br /> 4 :4V- <br /> Ity <br /> NOTES I MISCELLANEOUSwRelbSnature), Received By- (Signature) Date Time <br /> Relinquished By: ( gnature} I Re ived By: (Signature) Date Time <br /> del <br /> Relinquished By: (Signature) Received: (Signature) Date Time <br /> Method Of Shipment Description of Other Chains-Of-Custody 5:07, <br /> Dispatched By: (Signature) Date Time Received for lab By:(Signature) Date Time <br /> Transport Container Transported with this <br /> Chain(by Serial No.) <br /> XCI <br /> ' Send Lab Results to {Name): f Check Office Below) Verbals Requested: Yes ❑ No ❑ <br /> ❑ SANTA PAULA ON�STOCKT <br /> TEL (805) 659-0910 TEL KT 942-0181 E]VISALIA <br /> FAX (805) 525-4172 TEL (209) 734-9473 <br /> FAX (209) 942-0423 FAX (209) 738-6273 <br /> i <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br /> WHITE:Field Copy YELLOW:Pro" + r <br /> �Cop. PINK:Caborxtnry Copy <br />