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t 1 WL�r� <br /> Sou�B of Sample(s) WItJab No <br /> C7 <br /> Collector <br /> Address <br /> �G��`�vy. _ _ rrrn�r F� <br /> S _ � C��_�,,.,..,:5 Affiliation <br /> Address 375-a bw <br /> Phone 5%44e 5q G rA v \4e j CA <br /> Report to _ rj�e �C;IL [ate h e r vier L L K c . - - Phone _ C//(,— Y65-- S1678 - - - - <br /> Sample Information (1) <br /> Lab No Field No Date Time Type Depth Remarks (Suspected Contaminants Con <br /> (Lab Use Only) (2) tamers Preservatives Field Conditions, etc) <br /> gG`7S� C7 C7 <br /> 10logz Sail I24 `rq,l, jr-7 ("00010 -51E Cor,cr <br /> S Vy c <br /> U�.'?_ )0/i9/qo J d } rF T4-A 4r--; -- or-weir <br /> 003 1y/21ho Zt 11 ++ 1 Z�� T��•�� — /�e Cb+ r�er <br /> 7 Com' y Mfr CD�Z�'`f U I r y {t ! �� Icth�� 1 \!`'+OS��8�¢1) — /V <br /> CCC 1201 +r f� Cr T�...i� ;F l <br /> Chain of Possession <br /> Relinquished by Date Time Received by (3) Date Time <br /> (Signature and affiliation) r (Stgnature and affiliation) <br /> J <br /> 2 <br /> r <br /> Logged in at KIJ/C by <br /> �r <br /> (1)A separate Laboratory Analysts Request Form is to be idled ous by the collector and given to the laboratory when samples are delivered <br /> (2)e water sludge sod etc <br /> (3)It any samples are not intact at time of transfer please describe on the back of this torm <br /> Each batch of io or fewer samples of each mainx type(sott water etc)must include enough of one sample for triplicate analysis <br /> WARNING These samples contain unknown chemicals Mich upon analysts may be determined to be known to the State to cause cancer or reproductive to�tctty <br /> (Pri,t n 1y�31r', anci Inwic F,)Iorcernen+Act of 1986(Propositson 65) Ut?-6(LAS) <br /> PEN 1218r <br />