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Kennedy/Jenks/Chilton, Laboratory Division <br /> n Field Sample Chain of Custody Record <br /> Source of Sample(s) ,ll farm.% Collector <br /> I „_ •-- <br /> Address '2.0�� (�. wa-sl +vnwvN Affiliation Kis L <br /> S toGI +01A1 d-A Address <br /> Phone ( ) _._ -- 59lrrct M tKfo ; 6A --„ <br /> Report to ( 1) KOLr� ODAC,�k►M Phone I II&) - 11.,Z- 3Z5/ <br /> Sample Information K/J/C Job Nunber _ 'M15026-. 1)o� <br /> Type _. <br /> = Lab No. Field No. Date Time 2) Depth Remarks (Suspected Contaminants, <br /> Field Conditions, etc.) <br /> C; o,� <br /> 1 1 <br /> I l <br /> I / I <br /> Chain of Possession <br /> lRelinquished by Date Time Received by (3) Date Tire <br /> (Signature and affiliation) (Signature and affiliation) <br /> 2. <br /> Logged to 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 wnen samples are deliverea. (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 /> Eacn batch of 10 or fewer samples of each matrix type (soil , water, etc.) must include enougn <br /> of one sample for triplicate analysis. <br /> 'ARNING 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 /> i r <br /> t <br /> 1 <br />