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' Kennedy/Jenks/Chilton, Laboratory Division <br /> Field Sample Chain Of-Custody Record <br /> Source of Sample(s) Collector <br /> - Address -W10 W �k�ra5t� AfftlTation <br /> YL, t.,A _ Address 1UTA) <br /> Phone } Sf b <br /> Report to ( 1) W-k_• Ctju A Phone 14 j ';'/ <br /> Sample Information K/J/C Job Number . G� <br /> Type - <br /> i Lab No. Field No. Date Time Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc. ) <br /> 10A /too <br /> • AA 5q/94 <br /> l <br /> � S5- if SR ISS �►� --� <br /> Chain of Possession <br /> # Relinquished by Date Time Received by (3) Date Tine <br /> (Signature and affiliation) (Signature and affiliation) <br /> < <br /> Z. <br /> Logged in at K/J/C by <br /> (1) A separate Request for Analysis form 3s to be filled out by the collector and given to <br /> the Laboratory when samples are delivered. (Z) 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 /> ARMING. These samples contain unknown chemicals which, upon analysis, may be determined to <br /> be uknown 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 /> (7188) <br />