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_ FGL ENVIRONMENTAL AkIN-OF-CUSTODY RECORD q 3 PROJECT <br /> (See Reverse for Instructions) NO <br /> .PROJECT NAME 014A ( A) CO2R SAMPLERSU), Ho o -f2 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (P I T) DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER M W /f tr" A 40 ml VOA Vtai B Surface Water G Waste MSIandard <br /> I N) B Grass Liter (DBrass Tube C Leachate H Blanh peke 2 5 Day <br /> RECORDER �� Ab`4 r- C Plastic 500 ml F Other_ Rinseate LE)other Z5 r 3 60 Hour <br /> {SIGN) D Plastic Liter _ Sediment —ICi 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTArNERS <br /> `o AND $� g <br /> g na PRESERVATION $ • <br /> S e— <br /> g z SAMPLE <br /> 1'x¢ • aI ae Z 1L} -' �: :"�� NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID �g U LL 21 A o BOTTLE UPON <br /> l = NUMBERS RECEIPT NOTES <br /> �z 1010 - 4- x t^ Q <br /> 22 /04t G{J.. E .' ✓ X <br /> 112 <br />' 2 2 Zv til L(� S 7 ` �= ° "e t ��" <br /> 93n 4fuJ —6 t C-�rZ <br /> �/ 3 c7ts� Mcg -„ s�, - x / <br /> t�(z3 03s MtV <br /> -7 v <br /> _ Cha i <br /> 2 8 S AA W- 7 0 = v Y, VC l <br /> 5/2f 07/0-- 0` E y x <br /> r e SAN <br /> NOTES/MISCELLANEOUS g��rn -/c> CAN7Ff.1J ColtP 5,141-J Imq i hed4 t nature) R elved B �S1 nature) Date Time <br /> CiI of ��5��-1 5 T, I y+^� �-�Lt.�tr't/ { As-5 x Z 2-2 0 l lsh d y ( lgnature) Re I T78MU'l- <br /> Dat Time <br /> n QU {r, it (>+ �/'C7U �S�Lt' t � I1 ��z'� <br /> t ellnqul d sy (Signature) R served By (Signature) Date Time <br /> I <br /> Metho� 1 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 /> 10 ( 14, ,T Chain (by Senal No) <br /> Send Lab Results to (Name) �+► U v ,A5506 a?LZO � & 1)15-/c7 1S v (Check Office Below) Verbais Requested Yes ID No ❑ <br /> El SANTA PAULA STOCKTON ❑VISALIA <br /> TEL,(805) 659-0910 �� TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (804) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br /> FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • SfOCKTON, CA 95215 • TEL (209) 942-0181 • FAX (209) 942-0423 <br /> (LHITF Fi,ld Cip% )[110%k PA'jccr CP' PINK LjNwawrx (r,p, <br />