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Kennedy/Jenks/Chilton, Laboratory Division <br /> i <br /> Field Samole Chain of Custody Record <br /> Source of Sample(s)4�iQL—t�,P/j'J ScJPPLy Collector aC <br /> tdress�Qy4 �% /i9-5 1W65iTd/r-) �5�'41e <br /> 71�` <br /> ZZ <br /> Phone ( 1 5��,�Fi'/tl��Td J..�f� �5�2,Z <br /> Report to (I) .�G� �J!!'1 Phone <br /> Samala [nfar,a_Ton K/J/C Joo Numoer <br /> Type <br /> Lao ,Ya . =told No . Oa:-3 Time (2) Oeoth Remar' s (Sus'-ectad Con.aminants, <br /> Fiala Conditions , etc.) <br /> o-i� <br /> /ZOO Al �a <br /> ?.aY <br /> 11 <br /> z .<-4 <br /> Cnain a; Possession <br /> Relinquisnerf by Dace Time Received by (3) Dat_ Time <br /> (Signature and iii ati0n) (Sianai.ura dna af�iiiation) <br /> i- �---- v 419 <br /> z. <br /> Logged in at K/J/C by I I <br /> (Z) A separate Request for anaTysis form is to be filled out by the collector and aly ;I <br /> the Laboratory wnen samoTes are delivered. (2) e.g. water, sludge, soil , etc'- (3) Ff �•-� <br /> samales are not intact at time of transfer, Rleasa describe on the bact of this form. <br /> Each batc`T of 10 or fewer samples. of each matrix type (sail , write-, a:a.) must include a touch <br /> Of one sample for trialicata analysis. <br /> ' R"a"SIG <br /> N : these samoles concain unknown chemicals vnicn , upon analysis, may be ae_ermznec to <br /> be "clown to _-te Szaza to cause cancer or raoraauc-.i ve `QXi Ci�Y unde- tz2 <br /> Ori 1K i na '4a_a� cnc I aX i c3 Z-i orcamerir lc-. of 1°86 (Fr 0005 i v i on 65. ) . <br /> (7,'3$) <br />