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• <br />• <br />A4"�N SAN JOAQUIN COUNTY <br />Please send results to: <br />=Fp^5 Lh p..s <br />a �+ ENVIRONMENTAL HEALTH DEPARTMENT <br />Name: <br />r. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Y± `P Email: <br />Q<� o.R� Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Fax: <br />CHAIN OF CUSTODY RECORD <br />Name Title �1 / Date / J r Time Remarks <br />Relinquished by: � diA f r� ��� 1G (Z"t (2� `t :L S M <br />Received by <br />Relinquished by: <br />Received by: <br />Relinquished by: <br />Received by: <br />Rev 06/05/13 COPY HAIN <br />OF CUSTODY <br />Sample <br />container <br />description <br />Required <br />analysis <br />01 <br />�� number: 4f -9E <br />0 <br />n <br />0 <br />0 <br />Samplers name: ��} p�[C; � 2� � ( zt? <br />V <br />Title:-�o(Z IZI�-� <br />12 <br />0y <br />c <br />a <br />z <br />u <br />Unit: <br />v <br />'O <br />_ <br />r <br />m <br />y. <br />O <br />E <br />p <br />U <br />�z <br />(D > <br />Z <br />} <br />v <br />C <br />Sample address <br />Facility name: O JCS <br />u <br />°° <br />;° <br />c <br />E <br />c O <br />u <br />�1, J <br />Facility address: 000 C Q-fl� ijLa -, �"�[ cz_�v <br />4-� <br />Q <br />o <br />o <br />2 <br />CL <br />i <br />v <br />c <br />N <br />N <br />N <br />— <br />E <br />o <br />Facility contact: l Fiy4� �Iki� <br />-o <br />O_ <br />N <br />�0 CIL <br />u <br />o <br />U <br />c <br />u <br />c <br />C <br />v <br />o w <br />0 <br />w <br />o <br />T v <br />� <br />c <br />' <br />o. <br />M <br />J <br />^� <br />u <br />r <br />u <br />a E <br />n <br />' o <br />v <br />= <br />a <br />Lb <br />Sample <br />Sample location <br />Sample source <br />Date <br />Time <br />number <br />description <br />sampled <br />sampled <br />1- <br />� <br />F <br />_ <br />rc <br />m <br />l b DO OC41 H NNEl <br />y "A^— l '�.sz <br />�If <br />%1,1 <br />✓ <br />5mrnl <br />6� <br />✓ <br />✓ <br />� <br />'/ <br />Deo - Z <br />v- <br />✓ <br />✓ <br />Name Title �1 / Date / J r Time Remarks <br />Relinquished by: � diA f r� ��� 1G (Z"t (2� `t :L S M <br />Received by <br />Relinquished by: <br />Received by: <br />Relinquished by: <br />Received by: <br />Rev 06/05/13 COPY HAIN <br />OF CUSTODY <br />