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f <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJBCT <br /> ff (See Reverse for Instructions) NO. <br />;y PROJECT NAME t� .L' � � SAMPLERS � �^ I�S&� SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES p <br /> f _ _ p GRIN DESCRIPTION CODES AeGround water F. Oil <br /> i. PROJECT NUMBER ���. �� -�' l&'t'' ��e"#L <' (DA40-ml VOA vial B. Surface water G. waste (1�Standard <br /> (SIGN) B. Glass Liter E. Brass Tube C. Leachate �L31anklSpike 2. 5 Day <br />{ RECORDER C. %sfic 500-mi F.Other D. Rinseate I. Other 3. 60 Hour <br /> (SIGN) O. Plastic Liter E, SoillSediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS _ <br /> AND ` p <br /> PRESERVATION \}t� v9 0 v a a <br /> I. oo xo77 } ,i eEa ad SAMPLE <br /> °2 `w NOTES ASSIGNED CONDITION <br /> '. L E= °Y BOTTLE UPON <br /> DATE TIME SAMPLE ID N N z NUMBERS RECEIPT !NOTES <br />' op ItM-b5 A R 1 <br />,i p fl© -04 I <br /> I�. <br /> 1` NOTES!MISCELLANEOUS - R i quis ed by: (Signature) Re iived/By: (Signature) Date Time <br /> " <br /> Relinquished By: (Signature) _ eceived-By:-(Signature) I Date Ti" <br /> Relinquished By: (Signature) Received By: (Signature) Date Time <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 i t <br /> Chain (by Serial No-) <br /> roJ <br /> Send Lab Results to (Name): (Check Office Below) Verbals Requested: Yes ❑ No ❑ <br /> ❑ SANTA PAULA ❑ STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 TEL (209) 942-018t TEL (209) 734-9473 <br /> FAX (805) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br /> a <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAR • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br /> WHITE: Feld Capy YELLOW:Project Copy PINK: Lahuratory Cnpy - <br /> f <br /> f <br />