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Kennedy/Jenks/Chilton, Laboratory Diyision <br /> } Field Samole Chain of Custody Record <br /> I <br /> Source of Sample(s) of l ector . /.���/4r4 <br /> f <br /> • , <br /> Addresg4�10 ,+ Affi l iatiolr6 lmfh <br /> i d Address Q <br /> i <br /> 1 Phone l Z *� S����� <br /> pp <br /> Reoart to ( 1) Phone <br /> 5zmole Infarination Y/J/C Joo INumce,-6W2!W•4V <br /> Tyoe ` <br /> Lao No . Field :No Oaze Time ( 2) Oeoth Remarks (Susoect_d Con._minants, <br /> Field Condicians , ecc <br /> hw •Z• 1 �q S �. - <br /> 16L1 16 <br /> W- •��lb l ��_ �, ZD.S'21 <br /> 0 7 l0.?f 1.0 , <br /> Cllain of passasssan <br /> Relin uianea uy ca 3 <br /> 4 Oat, Time Rc__Trea by (�) Oat.. TTme <br /> {Sianatllr2 snG asi'1ITat1�n) (Ss4na�ure anQ ar!IlLation) <br /> s <br /> �• 1 I <br /> I I <br /> � I <br /> -I Logged in at K/J/C by / <br /> (i) 4 separate Request. for Analysis fomn is to be filled out by the collector and aife'i to <br /> the Laboratory when samoles are delivered . (2) e.g . water , sludge, soil , etc.. (3) If any <br /> samoles are not Tnzact, at time of transfer, please describe an the bac( of this torn. <br /> Each oatc� of 10 or Cawer samplas of each ma[ric cyae (soil , Hazer, etc.) must include enoua7 <br /> of onE sample Lor triol tcak_a analysis. <br /> 'AARN:MG These samoles Con-Cain unknown c`iemicals fvhicn , uonn analysis , may be ae_al-IOnec to <br /> 4e .�o yn to zrie Starz to f_ausz cancer or r?orr)aucti ire Ca (l C1 7'/" untie" C`.e C3I 1 ;or-.a $a-2 <br /> 0r f iif�i ll� 'ja:Er 1f7C 7] l z 1i Sr:� n f�] � a <br /> ;m� L mac, or ( r]aasa -lan a5 ) <br /> i <br />