Laserfiche WebLink
I <br /> Fray.lclir. �r I. M- - <br /> �AwJobOqo. <br /> tjr0e Of Sarnpie(s) ut55e�1 <br /> Collector - T <br /> Sf oc�l o /w.7�� vrhPr L�,i <br /> AHiiiation He o� <br /> Sw i 1 Cy;: �.. _ <br /> Address Address 375 0 A t6gr '\ blvj, Q <br /> Suitf A J[tCrQN1 OrCp4 f58Z! <br /> Phone <br /> �•�Q.�.�niCi`` a�-d <br /> L►, <br /> h,l'rhsr C. Phone <br /> Report to <br /> Sample information(1) <br /> Time Type Depth Remarks(Suspected Contaminants,Con- <br /> Lab No. Field No. Date tainers,Preservatives.Field Conditions,etc.) <br /> -_ <br /> (2) Ta.,k��(6600-5,A) S E Corner- <br /> (Lab Use only) <br /> CSU I 10/2 /yn 1 k 5VV Cor-eer <br /> I ' Tah <br /> lCYZ—= -, r #r n'C corner <br /> pG3 1v/z�lYu RI11 tt 1�-� T.twl, r <br /> ----� r� n t/1J' <br /> -`�U^�— �^ I f � f fct+.i� #� lr�'�WO 9a��— �fE Corv,f <br /> i <br /> 7 <br /> Chain of Possession pate Time <br /> Date Time Received by(3) <br /> Relinquished by (Signature and affiliation) <br /> (Signature and alliliation) <br /> /U �•�c`^/� ! <br /> Logged in at KIJ,C by <br /> (1)A separate Laboratory Analysis Request Form s to he Idled oul by the COIL,or and piwn to the laboratory when samples are delwered <br /> t2)eg water,sludge,snLl.elC <br /> h of one sample for lripl�cale analysis <br /> 11 any samples are not Intact al Ilme OS UBnsler,Qlease de5crtbe et She back of this form <br /> Each batch of tD or lever samples of each matrix type iso'I•wafer,etc.,mus,include enough 18tr 6(LAB' <br /> WARNING mese samt lec contain unknown ahem ccn rwl nl'upon n a 8h'imay <br /> Po ton 65hned to br'known to the State to cause cancer or reproduc!we iRe`t21 B <br /> I.... ty <br />