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Field Sample Chain of Custody Record Kennedy/JenkkChl ton <br /> Laboratory Division <br /> E <br /> Source of Sample(s) CA L PAD w\. KIJIC Job Na2-5.Z6 O <br /> Collector <br /> } Address ��-t0.�6�V�� W__ „— Affiliation �— <br /> Address S <br /> Phone <br /> 1 Report to Phone <br /> Sample Information(1) A <br /> Lab No Field No Date Time Type Depth Remarks(Suspected Contaminants Con <br /> } (Lab Use Only) (2) • tamers, Preservatives, Field Conditions etc) <br /> 4111199 Y, OX, <br /> 41,218? <br /> Qc. $3 Vy1 u! - Z 16'3s Sx u0c,c4d , <br /> qmtl . <br /> 1145 <br /> I <br /> Chain of Possession <br /> Relinquished by Date Time Received by(3) Date Time <br /> i (Sigure and affillation) (Sig Lure and affftliation <br /> hL <br /> A'4L'4 <br /> 2 <br /> , <br /> w <br /> Logged to at W/C by 4zjz:�e <br /> 11 <br /> . (1)A separm Laboratory Analysts Request Form is to be filled out by the collector and given to the laboratory when samples are delivered <br /> (2)ag water sludge,tial etc. <br /> (3)If any samples are not intact at time of transfer please describe on the back of this form <br /> Each batch of 10 or tewer samples of each matrix type(sal,water,etc-)must Include enough of one sample for triplicate analysts <br /> WARNING These samples contain unknown chemicals which upon analysis,may be determined to be known to the Slate to rause cancer or reproductive toxicity <br /> under the CaldornW Safe Dnnking Water and Toxics Enforcemerd Act of 1986(Proposition 65) <br /> Lab-6(LAB) <br /> Note Top(Ongtna)copy to laboratory wdh samples <br /> Rev 12188 <br /> I <br /> J <br />