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SAN JOAQUIN COUNTY <br /> 2 y� Zyzl?-�b(v Please send results to: <br /> { ENVIRONMENTAL HEALTH DEPARTMENT <br /> Name: rre <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 Email: <br /> �rF R�'• Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> Fax: Vc'l <br /> CHAIN OF CUSTODY RECORD <br /> ^� j Sample container description Required analysis <br /> RO number: <br /> J <br /> 1 r E <br /> i <br /> O <br /> O <br /> Sampler's name: ����� _C1G � �? d v <br /> a a z <br /> Title: 45H---, a ° v <br /> z <br /> U 3 <br /> Unit: N r <br /> _ 0 z Y <br /> Sample address E z E <br /> 0 v ? ° v <br /> Facility name: 1pe-lo -2 �( °�° a <br /> c `vO~ Nc > v cv <br /> N E <br /> Facility address: 44 l T-- _,f-A E mg <br /> N a E fl a v v O a t <br /> d ;; y u u E <br /> E N n r ° v E > 3 Y <br /> Facility contact: [ r rv�c�'Ti+� - ?tel Y �.Z/ �"'ajc^ o N O M c a c N E o f o <br /> Sample Sample source Date Time v v >v > ? 9 @ m = <br /> Sample location r 2 w r 1 u u - m a m <br /> number .J ^ description sampled sampled /' <br /> e- L7Sf?,�L./yJ(`i ilrcJ, j 7 r 67- a~'t <br /> Name Title Date Time Remarks <br /> Relinquished by:: Yi ,�� �� Cir �� 4�� `1 Z ' i, �✓/ys�._- X �.. 4 f o,� �-/r'? t---y7'• <br /> Received by ✓ J1 leif <br /> Relinquished b t <br /> Received by: �7 <br /> � <br /> Relinquished by: `/ ' le ? 7/ZZ 1-SZ�w _ <br /> Received by: �.Ji 3 ��/�►-c. <br /> Rev 06/05/13 CHAIN OF CUSTODY <br />