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Kennedy/Jenks/Chilton, Laboratory Division <br /> Field Sample Chain of Custody Record <br /> Source of Sample(s) �� f-'O'r M _ Collector Leill 6 Laad 014 <br /> iAddress ?.0 y11' +a Affiliation AfTG <br /> L� c�A <br /> 7'{�,��QI(\, Address <br /> Phone ) SCcC Q�l��t."�, e-A <br /> Report to ( 1) A0.IIk 'OC.Euw! Phone ( Q((o ) 3GZ--3Z5f-- <br /> Sample Information K/J/C Job Nunber 9925(RZ�n <br /> Type <br /> Lab No. Field No. Date Time (2j_ Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc.) <br /> IA /9 /84 490 <br /> /q / 9 <br /> 000 <br /> ss� 3a Si l a9 oQ3o � <br /> 1 Chain of Possession <br /> Relinquished by Date Time Received by (3) Date Time <br /> (Signature and affiliation) (Signature and affiliation) <br /> 2. <br /> Logged in at K/J/C by I I <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 /> Each batch of 10 or fewer samples of each matrix type ( soil , water, etc.) must include enough <br /> of one sample for triplicate analysis. <br /> ' 4ARNING 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 hater and Toxics Enforcement Act of 1986 (Proposition 65) . <br />