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aRECORD <br /> + <br /> PROJECT No. . CHAIN OF GUSTO JY �E C O 13 d <br /> SITE NAME& ADDRESS <br /> �a 1003.07- SC <br /> (ZVS ANALYSES REQUESTED (t} <br /> ,AS1A <br /> W1TNJ=SSlNG AGENCY/ <br /> INSPECTO M <br /> ` NAME/DATE <br /> !D NO. <br /> DAu °tl y m <br /> TE TIME <br /> �? x °� �' REMARKS <br /> O SAMPLING LOCATION . �- p m °a <br /> x � x 0) x <br /> C- FzsNot/gZ o� ✓ �`�Y5 N L c <br /> C-FFLU t`N j <br /> .y. <br /> C I <br /> ii <br /> inqu' h b <br /> Y (SignatureJ {1} attached <br /> Date/Tim, See <br /> Received b 'Table 2- <br /> Relinq sh b <br /> Y: (Signature) for speclflc analysis method. <br /> The following MUST 13E <br /> Y (SignatureJ for analysis; completed by the laboratory <br /> Dale/Time Received b : i. Rave all accepting samples <br /> Y (Signature) samples received for analysis been stored in ice? <br /> Relinquished by: (Signature) 2. Will sem !es rs <br /> Date/Tlme p main refrigerated until analyzedp <br /> Aeceived by: (Signature) <br /> 3• Did any samples received for <br /> Relinquished by: (Signature) analysfa have head space <br /> or ; <br /> DatwTime Recd for Laboratb a• were samples in a <br /> containers and <br /> Y y (SignatureJ ppropr!ate <br /> (rproperty packaged? <br /> Z� 9 Signature <br /> 1.'r � 2"fit 1 aNt�llifia. TiNa �L. <br />