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k <br /> RECEIVED <br /> K NOV 2 8 1989 KAPREALIAN ENGINEERING, INC. <br /> 4 <br /> WW-N1'IRONI!ENTAL HEALTH CHAIN OF CUSTODY <br /> PERMIT/SERVICES <br /> ixI SAM?rm. SITE NAME 8 ADDRESS I ANALYSES REOUESTED I TURN AROLIND TIME: <br /> -'y L 3 i w l ^i '-4 I l l x¢ <br /> IWIT EBBING nuc ! "*ifs-e- � • y! <br /> I 5.1 CH <br /> jI I ! I !GRAB! No. I ! 'Al 1 <br /> SAMPLE <br /> I ! I I I mo ! OF ! SAMPLINGI kI p +! i I 1 . I R l: !1 A R K S ] <br /> ] ID NO. ] DATE ] TIME I Sall ]ti1+IFER]DDFPICONT.I LOCATION f PIS,QI ! ! I ! <br /> i <br /> ic <br /> I AZ I i 1 e_ 1 I I I ! v 1 ylYl I I f I i <br /> zf.7 1 <br /> 1S`L I I I I l y I i I I ! <br /> Yl ✓lt/I I I I 1 I <br /> I I 1 f I I ! I I 1 1 ! f I I ! I <br /> I f ! I I I I I I 1 ! 1 ! ! ! I I <br /> f <br /> I <br /> 1Reii h by: ignature) I Date/Time I Received b"Signature) The following MUST BE completed n onp by the laboratory accepting samples i <br /> II] fl S° ! �� for analysis: <br /> IReiirxluished by: (Signature) 1 Date/Time Received by: (Signature) 1. Have all sarples received for analysis been stored in ice? <br /> ! � I <br /> iI 1 2. Will ! <br /> samples remain refri erated rntiE analyzed? 1 <br /> ]Relinquished by: (Signature) I Date/Time I Received by: (Signature) 3. Did any samples received f r anal i <br /> I ! ysis have head space? 1 <br /> 1 14. Were les in a opr 1 <br /> -,ished samples ppr iota containers and properly packageN <br /> by: (Signature) I Date/Time I Received by: (Signatur�' Zu <br /> Signature Ti I le Date I <br />