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' pie Chain of Custody Record Kennedy/Jenks/Chifton <br /> Laboratory Division <br />' of Sample (s) � - c 's. t, a_ iA4M Job No <br /> �fUtf� {-t„ uh� ;e� s��•pt• �is�r�<+ Collector <br /> 1 ,ddress 5frrt� "r` 1111-r�r +•.a Afflbatlon ��ej�^ ;tic �erner , Stir+. <br /> Address 3 75-6 A..+` ten NJ S- 4 <br />' <br /> Phone X1 <br /> ICrCLM*Jo Cit, 758z,J <br /> 1 <br /> Reportto Yej-o, c&•^A r-nef Zh q Phone r 16 - <br /> Sample Information (1) <br /> t Lab No Field No Date Time Type Depth Remarks (Suspected Contaminants, Con <br /> (Lab Use Only) (2) tamers, Preservatives Field Conditions etc) <br /> V oc) s /0/31 /4 r, 1 5, 13-04 7-ank #I Qc,00() tel • S w corner- <br />' D O 10/31/10 . D It )3.0 70,,.1( #! 1- /Iltry C.orll%er <br /> 7� �%I p 1v/3r ho 075-3 it Z� ; Tank # n 4 z +t <br /> 1 r � 0 iP++��. .r��1�1��_ <br /> 7 �� j f q Ti Tix"� #./ Ce itr` -- <br /> 17 ,��? 1Q`31I�Jr� 1�zf� t+ ,'3 �� 7a�� (bGAOS'i)L. w- <br /> 1 <br /> Chain of Possession <br />' Relinquished by Date Time Received by(3) Date Time <br /> (Signature and affiliation) (Signature and affdlation) <br /> r r I C 4 r /3t �f r,. 1q1 <br /> > <br /> 1. /31 l�ly l y/� ¢jiver Yc., fj.�P.i('tii....� ►0 1 <br /> 1 <br /> 1F :21 � <br /> /0-0 <br /> Logged In at KIJIC by 112Zr4e � <br /> (1)A separate Laboratory Analysis Request Form is to be titled out b� the collector and given to the laboratory when samples are delivered <br />' (2)e g water sludge sod etc <br /> (3)if any samples are not intact at time of transfer please describe on the back of this lorm <br /> Each batch of 10 or fewer samples of each matrix type(soft 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 />