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Please send results to: <br /> SAN JOAQUIN COUNTY <br /> Name: l�i� <br /> f` ENVIRONMENTAL HEALTH DEPARTMENT .1111_ ( <br /> ( Finall: mnaiduh�Sjcend.com& ebackus Wsicehd corn • J <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd�gov.or g� "EHD staff to call for further instructions:Garrett Backus <br /> (209)468-2986,Michelle Henry(209)468-3453,Kasey Foley <br /> CHAIN OF CUSTODY RECORD (209)468-3451' <br /> Sample container description Required analysis <br /> TA number. A z z I E <br /> Samplers ` 1 I` 1 (/� _ u �a o 2 0 <br /> (_V 6- u �o � _ o <br /> name: e� a ° a o �o <br /> C N r (u r v v N <br /> Title: m ry N N <br /> C Z m m w N v au—+ N lO <br /> N 6 <br /> unit: " �? V " `? a ? c a . N <br /> O m l0 u <br /> J u f0 to N N <br /> Sam oleaddress Y ° N z N i v a ° <br /> E Z5 > Z T u � z 4Y a � E LO � � <br /> 1 f1 V U 6 m O O O N Z D 2 2 K N F <br /> '((�� C O C D N N u U <br /> Facilityname: I V V m 2 c o N � � °` � °� u � u u v ra <br /> a O U > U m U F N N ~ <br /> Facility address: 1t/{�/ E v .c N N LL u ' 01 I E ° a, a _o <br /> y �� \Y' 1 1 v (�,q Vii O. N E 1= ;L <br /> Y d <br /> Facility contact: ✓ 1 {� C I ( G E " S 0/ _' N °1 ~ <br /> o <br /> Sample Sample source Date Time v v o v o J J E ° _ ' S o ` c° <br /> number Sample location description sampled sampled ~ w ~ 8 ~" 5 u v °�° cc u m <br /> �'�� r� , -o i <br /> Name Title Date Time Remarks <br /> Relinquished by: {��` Y� j � I I L G �_ 1-0 c{ <br /> Received b /l] ; �l� Ig!✓T Temp C LASFR #1 <br /> Relinquished b <br /> Received by: Vf r;cy N(QY711 ee 11120 <br /> Relinquished by: <br /> Received by: <br /> Rev 02/05/2019 CHAIN OF CUSTODY <br />