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P.O. Box 576981-6981 <br /> M.J. Kloberdanz & Associates Modesto, California 95357 L I q5-- oq <br /> Environmental Services Phone: (209) 577-8186 Lab Report# <br /> Regulatory ❑Yes [:]No <br /> Fax: (209) 577-8158 <br /> Regulator: <br /> Phone: ( ). <br /> Client. r ��c L CHAIN OF CUSTODY Fax: ( ) <br /> Address: To: <br /> CIO" Zip <br /> Project ID C X Lab Use Only <br /> (Prin) e) C > N <br /> Sampled By t' K�s –���.� w ---- y Q �C a) <br /> Ign Container U Q ) Z <br /> S mple t�pe / �� Lab ID # V) <br /> Date Time ample ID I'Nre Size Z <br /> Grab Com Matrix <br /> " E _ i Remarks 3 Y y7 # <br /> (r f - v _ If L— 76 <br /> -13'1'177 <br /> o r - - i _ L L3 71 <br /> - , L �-v <br /> - c <br /> -W - 14- 0 <br /> �( r <br /> ' U fr P <br /> Remarks <br /> fro -T�pr\ cV- -40 �,f0kan --fk"^�" 5�3�100 <br /> Relin i ed y( gn ture) Date Time R ce y(Signature) _ Date Time <br /> 5 �y /;od �— 2Yoo ((CFO <br /> Relinquished b Signature) Date Time Receive by(Signature) Date Time <br /> Preservative: <br /> Site Time: Driving Tim: Total Hours <br /> Star. Finish- Total Hours: Start:: <br /> Site Arrival: tit- <br />