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Kennedy/Jenks/Chilton, Laboratory Division <br /> Field Sample Chain of Custody Record <br /> Source of Sample(s) CQ.�' �Q�jN_ _ Collector _ L46 Ie <br /> . Address 1040 GJ. Vf Affiliation r—/S& <br /> C� Address <br /> --- 33-5& 3eRW611Q c,7 Sic /qo <br /> Phone <br /> Report to ( 1) _ AA 0-aum _ Phone 1116 <br /> Sample Information K/J/C Job Number ,aa <br /> a <br /> T <br /> Lab No. Field No Date Time (2) Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc. ) <br /> r <br /> s- 5 5/q / <br /> Ss- CaB S 9 / <br /> sa S/9 <br /> V5 11A <br /> Chain of Possession <br /> Relinquished by Date Time Received by (3) Date Tine <br /> (Signature and affiliation) (Signature and affiliation) <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 fors. <br /> Each batch of 10 or fewer samples of each matrix type ( soil , water, etc. ) must include e*iough <br /> of one sample for triplicate analysis. <br /> URNING These samples contain unknown chemicals which, upon analysis, may be determined to <br /> • -)e "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 /> (7/5a <br />