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74;-�o7 <br /> ' I <br /> Xennedy/u-aks/Chilton, Laboratory Division <br /> `-' Subcontract Sample Chain of Custody Record <br /> Source of Sample(s) KENNEDY/JENKS/CNILTON Subcontract to <br /> Address 674 Harrison Street Attention <br /> San Francisco California 94107 Address <br /> Phone X415 ) . _362-6065 <br /> Report to (1) Leverett Smith or Ted Nakamura Phone l <br /> Sample Information K/J/C Job Number. L cc <br /> Type <br /> Lab No. Field No. Date Time Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc.) <br /> r, TYA <br /> r.- t A,_n T7 <br /> Chain of Possession <br /> 3 <br /> Relinquished by D e Time Received by (3) Date Time <br /> (Sigpature and affiliataon) - (Signature an affiliation) <br /> 1. II Qti //-5 <br /> 2. <br /> Logged in at K/J/C by <br /> (1) A separate Request for Analysis form is to be filled out by the collector and given to <br /> the Laboratory when samples are delivered. (2) e.g. water, sludge, soil , etc. (3) If any <br /> samples are not intact at time of transfer, please describe on the back of this form. <br /> . WARNING: These samples contain unknown chemicals which, upon analysis, may be determined to <br /> be "known to the State to cause cancer or reproductive toxicity" , under the California Safe <br /> Drinking Water and Toxics Enforcement Act of 1986 (Proposition 65) . <br />