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AaD1ry SAN JOAQUIN COUNTY <br /> ,o••' " • •c�c Please send results to: <br /> a tia ENVIRONMENTAL HEALTH DEPARTMENT <br /> m � Name: <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 Email: abr-c,(G�s� <br /> Q• Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> a�rFoa�� Fax: <br /> CHAIN OF CUSTODY RECORD <br /> Q Sample container description Required analysis <br /> RO number: (� 7. <br /> 0 <br /> Sampler's name: <br /> Title: ✓ t� a z a <br /> •� u <br /> U 7 U } <br /> Unit: 1° <br /> o U 0 z c <br /> Sample address °• v <br /> E u > 0z o <br /> o v <br /> U N O U U <br /> Facility name: P 3 <br /> ��� —2rl/ 6b c 0 v v N <br /> 9 / / O o } u Z E <br /> Facility address: `-� '61-7 111!, i — <br /> 4 m v <br /> °0. <br /> a -o v v v <br /> 0 w al CU <br /> Facility contact: G4 r 1" i`r"�r 1e �i✓pcP p u°�`' 66 u o w _ - (1) ° C > <br /> 0 0 _ c a ti E v m o <br /> Sample Sample source Date Time v a >v ° FU N u LL c m � a m <br /> number Sample location ram 1"description sampled /sampled <br /> /�+ ~ "' ~ <br /> f"1 i„3�"�'✓`�'^�G° L�+�.�c-�•za.-3�+a,' y '7 /7 / (/',�c� t.�^ �ay2 C`7' M <br /> Name Titl"e Date r Time Remarks <br /> Relinquished by: "�.® ly `f/ Z— /� f�' S�a>.--_ xr� s' � i L -�i� ;, le ` <br /> 92 <br /> Received by <br /> Relinquished b �� ti V <br /> Received by: /[' 96-w lC 2/, 2- ✓ v <br /> Relinquished by: <br /> Received by: <br /> Rev 06/05/13 CHAIN OF CUSTODY <br />