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CHAIN OF CUSTODY RECORD <br /> PROJECT NO. SITE NAME& ADDRESS <br /> ANALYSES REQUESTED (1y <br /> 64 <br /> WITNESSING AGENCY/INSPECTOR NAME/DATE <br /> �11 m ur .4 z <br /> IYa�E 3 m W 6 CD REMARKS <br /> °tl �t3 � � <br /> L7 O m X <br /> ID NO. DATE TINE O ¢ SAMPLING LOCATION k = m m �+ �' <br /> rn 3 M z M z <br /> Y: <br /> .on. <br /> Ts- ?rA <br /> 3 ho e"TS r-FLUe=,Ar <br /> K: <br /> s- <br /> (1) See attached'Table 2' <br /> for specific analysis method, <br /> Relinquishby: (Sig tui �7 / �Da)e/TIme Received by: (Signature) The following MUST 6E completed by the laboratory accepting samples <br /> Lrt(l�rF 9 y� to for analysis: <br /> If1. Have all samples received for analysis been stored in ice? <br /> Relinquished by: (Si ature) Date/Time Received by: (Signature) <br /> 2. Will samples remain refrigerated until onafyxed? <br /> Relinquished by: (Signature) Date/Tlme Received by: (Signature) 3. Did any samples received for analysis have head space? <br /> 4. Were samples In appropriate containers and properly packaged? <br /> Relinquished by: (Signature) Date/Tlme Rec'd for Laboratory by: (Signature) <br /> 117- L � Signature Title Date <br /> CEI�ECON <br /> CALIFORNIA ENVIRONMENIAL ENCINCEK & (f)NIRAGrORS �P <br /> 7'> PAP-91A AVr 4'A"If-11 A "n 1)jfl,l.l r I i,,) - , i <br />