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FGL ENVIRONMENTAL CAWN-OF-CUSTODY RECORD � P) o.iEcT <br /> See Reverse for Instructions) <br /> 7NO TSS <br /> �1C�1'12r"�C( NPYQd SAMPLERS • 44 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PROJECT NAME AN) <br /> DESCRIPTION CODES A Ground water F WasteOn <br /> A 40-Ml VOA Vial B Surface Water G nk/ t Standard <br /> PROJECT NUMBER�� B Glass Lues E Brass Tube C Leachale ii Blank/Spoke 2 5 Day <br /> i Other 3 60 Hpur <br /> ��) C Plastic 500 ml F Other � H,eseale <br /> RECORDER W4 t4 r D Plastic Laer E So+used,ment 4 Other <br /> (SIGN) <br /> NumBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS 1 <br /> c AND $ n w <br /> �— &Z PRESERVATION ,^ x g o� �— 1 <br /> v SAMPLE { <br /> ag ag E NOTES ASSIGNED CONDITION <br /> Et _ r° °- BOTFLE UPON f <br /> 1- N z NUMBERS RECEIPT NOTES <br /> DATE TIME SAMPLE lD ^ <br /> 1• �! Cr7 ( Acd gr <br /> I/C. r ))t ii YehCkl ! ! <br /> l r.Tb C r!G At ( 1 <br /> 1114/Y Z4 d 3 rr� A <br /> u1c.14 r t! <br /> ------------------ <br /> ----------------- <br /> mq I ed Si nature) Rece ed By (SI nature) Date Time <br /> NOTES I MISCELLANEOUSIG s�4ltc� rO',% 7� 0-/ �� ✓ S� <br /> Frm r-6 L 1, c64 f� <br /> lhS L ! t 11 q i tied By (Signature) reiv (Signatur ) D e Time <br /> c/Df�LfYi�z YYod�Cou _'f �//r�•� Received B gnalure) D to Time <br /> P� I�iC (CY7 0 �'{OG� 9�Zgg e lnquls e y e) Y <br /> Method of Shipment Description of Other Chains-Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial NO) <br /> Send Lab Results to (Name) rl? J, y SrGZZZo ga (Check Office Below) Verbals Requested Yes 4�1 No ❑ <br /> ❑ SANTA PAULA �!G 1 97L_7f41 ❑ STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 FAX 04) Q7Z- TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (805) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL (209) 942-0181 • FAX (209) 942-0423 <br /> WHITE Field Copy YELLOW Projecl C,,p) PINK L.it if,mr)L,-py <br />