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Kennedy/Jenks/Chilton, Laboratory Division <br /> Field Sample Chain of Custody Record <br /> Source of Sample(s) yN Collector Z ^)v& <br /> Address Affiliation <br /> co in,._- Address ,at3k <br /> Phone {.!_lrL) 30 S� _ _ a/N6!* G.4 <br /> Report to ( 1) MAd= Phone <br /> Sara le Information K/J/C Job Number (r. <br /> Type <br /> Lab No. Field No. Date Time (21 Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc.) <br /> - l <br /> U 57-4/35 <br /> OS- ID 1 r IG <br /> Chain of Possession <br /> Relinquished Dy Date Time Received by (3) Date Time <br /> (Signature and affiliation) ` (Signature and affiliation) <br /> i <br /> i 2. <br /> l <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 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 /> IARNING These samples contain unknown chemicals which, upon analysis, may be determined to <br /> . oe "known to the State to cause cancer or reproductive toxicity", under the California Safe <br /> Drinking Water ana Toxics Enforcement Act of 1986 (Proposition 65) . <br /> (7"S <br /> t <br />