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0 4u IN cF I ) 1`1 D I Please send results to: <br /> o SAN JOAQUIN COUNTY w <br /> �)i/? I l <br /> H < Name: <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Email: mnaidu@sicehd..com& ¢backus@sicehd.com <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 1 <br /> P g <br /> . <br /> g <br /> . <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:wwwsjovor /ehd <br /> a��FORta 'EHD staff to tall 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 /> 1 Sample container description Required analysis <br /> 1C^ <br /> TA number: 1 1� — — <br /> � `, E <br /> Sampler's a G M G C) /1 <br /> name: 061� �� ' 3 v <br /> Title: <br /> 1 u a u - N a ry \Y <br /> E 0 <br /> d z 00 m 2 -2 N N a <br /> 7 N <br /> U a <br /> Unit: y?j a y z LL LL � v ry <br /> O K N oc N d N N I U <br /> O ro v O O ti r4 <br /> Sample address no y 0 ^ z N z u w a N u N —� <br /> '� Q y u u0 r j N U vOi U U Y > <br /> FacilityCr <br /> name: Ycc <br /> u _ m # <br /> r 1 'Q 00 Ou > } .F. , C' O H N a N N �' <br /> Facility address: \.II �� E v .S u N m u m = —°„ v a o <br /> �j N a Q a N <br /> ,n I -y�`Llr r✓ p E a a <br /> Facility contact: V� 1�1 `1 ����� o a E > 3 �� <br /> ` 1 <br /> 0 0 — c n F -w Fw E °- > v1 <br /> IV IYo 0 0 <br /> Sample Sample source Date Time v (U a s � m < < m L LL o <br /> Sample location v > U • • u u m 0 US <br /> a, <br /> number description sampled sampled <br /> .�N, #s( «VrVCr '��� 011e.,{ gCvQ iU Ili �:�(,� rn 3-} X �C <br /> 14 I q �-- y y <br /> it-y"c3twQi PYCauLfiDn v <br /> r i A v A 01 r_t YCt t l U I I IG 3,•4{) to (a- j ( .y / �C x k -DZ <br /> Ab tion rte p►�a�n t3ui <br /> I <br /> Name Title Date Time Remarks <br /> Relinquished by: 1 119 <br /> Received bye 1 1 r4m R #1 <br /> Relin uished b r� 1 �Ifna <br /> q ' b ( '/ I1:00 An, III I iq - Uiortss��A Gail - 03 pFe .Muco <br /> Received by: D �7 % 1100 <br /> l l/l3 I C = 6 STLC� <br /> �e <br /> Relinquished by: TQ Z— (STLC L TC LP) Ie.1 a M(4af <br /> Received by: —V 3= Cr ( LC) <br /> Rev 02/05/2019 CHAIN OF CUSTODY <br />