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Please send results to: <br /> SAN JOAQUIN COUNTY l/- <br /> �= Z\ K I Name: ILK:.)i: \!: <br /> ENVIRONMENTAL HEALTH DEPARTMENT O'' �� <br /> Email: mnaidunsicehd.com& ebacku0&sicehd com \J <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd .EHDstaff tocall 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 I Required analysis <br /> TAnumbeJ_ 11 1� Lig — E <br /> Sampler'sme: LV 1 �1 ,6r o F; Ma o <br /> name: o <br /> a w N ? Q o fo <br /> Yu <br /> CO Cu r U H N V N <br /> Z C a <br /> Title: o H <br /> � `� „ � •� ? C ? „ a '� ,�, � <br /> '. .— v v a N N <br /> C Z v m N m « ti LO <br /> Unit: ca <br /> a (u 'y LL N LL N N O N M (Np U <br /> in O f0 "" l02 U3 0- Nto <br /> U <br /> N N <br /> Sample address o } O N z V z cc v r N U N <br /> E V a > z ° m oz , z u s° I E so � N le <br /> - U C C (] p O ? 0 j Cr a K N F <br /> Facilityname: NP SjJC� ft m m to } � to t � � `C, U � H U � a <br /> /V '' V I a O O > } N 0 nc O F N I a N !NV ~ t0 <br /> Facilityaddress: 1� �� E v a N c' m U m = °/ w a = 9 <br /> Y nK w� �e srT E Z LL N LL Y <br /> a a v v G N N a ~ ao ~ ~ L <br /> Facilit contact: 1 f 1 ' 1 0 ,EM, S° r ° > ; y w <br /> o O <br /> Sample Sample location Sample source Date Time v ad a 5 a) ' o L <br /> number p description sampled sampled ~ ~ ~ ~ • ^ U U m U m <br /> I , 0- I� l� lG' , Cv- 5 U y y x x x x 01 <br /> Name Title Date IG I I Time m Remarks <br /> Relinquished by: 1 /` ` 1 V ' I (---4/t 1 ' <br /> Received b �!� ; Iy r9m Temp 3. 'L C LASEER #1 <br /> Relinquished b G <br /> Received by: Vf� ce Jt/tQYtIL[fC'�' l�" 7—/y 11120 (Irl S(I Pb(STt.0 ti.TC P) added <br /> Relinquished by: <br /> Received by: <br /> Rev 02/05/2019 CHAIN OF CUSTODY <br />