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KAPREALIAN ENGINEERING, INC. <br /> CEl11IN OF CUSTODY <br /> J I SITE NAME b ADDRESS I ANALYSES REOUESt& I TURN AR"D TIME <br /> 15AMplER ! <br /> (,/A/OCft-T-- <br /> IWITNESSI <br /> NG AGENCY <br /> 1 1 1 1 1 1 1 <br /> NO2 <br /> I SAMPLE I ! I I I I I OF I SAMPLING I p�I T II A R c s j <br /> I <br /> k ID NO I DATE I TIME I SOIL IWATERIGRASICCMPJCOHT.I LOCATION ( I I I I <br /> } ! k I I � I 'Xk <br /> flip.)r� <br /> I <br /> I I I I { 1 1 1 I <br /> I I { I I I I I I I <br /> I l l l k l l l I <br /> I I I I I ! I I I { <br /> 1 1 1 1 ! ! 1 1 I <br /> I I I I I I I I <br /> I I I I 1 I I I I I <br /> l l { I I I I I I <br /> I I I I I k l l l I I <br /> the following MUST BE completed by the laboratory accepting samples I <br /> IRelt i hed by, Signature) I Dateltime I Received by. (Signature) I <br /> for analysis: <br /> )-V rte` 1 Have all samples received for analysis been stored to :ceT I <br /> Relinquished by. (Signature) I Date/Ti I ved (Signet e) <br /> ! <br /> I12. Wtli samples remain refrigerated until analyt:ed7 <br /> 1 I <br /> 1 Date/Time Received by. (S e) 3. Did arty samples received for analysts have head Spaces <br /> ,Rcrtnqutshed by. (Signature) i <br /> I I I � I <br /> I I 16. Were samples in appropriate containers and properly packagedt R`{ <br /> Ipeltnqutshed (Stgna'ure) I Date/Time I Received by (Signature) -� I <br />