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Kennedy/Jenks/Chilton, Laboratory Division <br /> Field Sample Chain of Custody Record <br /> Source of Sample(s) _-,t.f— )GxrmCollector (X5)1e 1A1t,d&V1 <br /> Address -LOL/0 1a Affiliation - X�'S�G^ <br /> ^_�L�V1 Address _ 3331'0 8 5t'Y,c t� .5 f'r- 15�D <br /> Phone ( )� 6acArgr1G <br /> Report to ( 1) NLA I'Oat4M Phone <br /> Sample Information K/J/C Job Nunber <br /> Type <br /> Lab No. Field No Date Time (2) Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc. ) <br /> WS- ► <br /> WS�T <br /> - aB yql � D <br /> 2 14 vim. <br /> Chain of Possession <br /> Relinquished by Date Time Received by (3) Date Tine <br /> (Signature and affiliation) (Signature and affiliation) <br /> _r <br /> 1 <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 enoua_n <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 Dater and Toxics Enforcement Act of 1986 (Proposition 65) . <br />