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FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD <br />(See Reverse for Instructions) <br />LAB PROJECT <br />NO. <br /> <br />PROJECT NAME 1\16 V I i, krki __ tie."-> SAMPLERS MFI 5 SAMPLE CONTAINER <br />„—DESCRIETIQN CODES <br />(A. 40-ml VOA yjaL._--, <br />B. Glass Liter E. Brass Tube <br />C. Plastic 500-ml F. Other <br />SAMPLE DESCRIPTION CODES <br />(47 Ground Water _e; F. Oil <br />R—SOrrace Vra-gr - G. Waste <br />C. Leachate H. Blank/Spike <br />D. Rinseate I. Other <br />TAT CODES <br />1 Standard <br />5 Day <br />60 Hour <br />Other _ <br />(PRINT <br />PROJECT NUMBER --'...kyri)L.-6.1- c..) <br />i (SIGN) <br />RECORDER E. Soil/Sediment D. Plastic Liter (SIGN) <br />DATE TIME SAMPLE ID Sample Container (enter code) Sample Description (enter code) NUMBER OF <br />CONTAINERS <br />AND <br />PRESERVATION Field Filtered (Check) ANALYSIS REQUESTED TAT Requested (enter code) Maximum Holding Time for Method Requested Sample Stored at 4°C (Check) No VOA Headspace (Check) CONDITION NOTES <br />LABORATORY USE ONLY <br />ASSIGNED <br />BOTTLE <br />NUMBERS <br />SAMPLE <br />UPON <br />RECEIPT NOTES ___ <br />TNI <br />13 <br />I <br />o 1' -**'' <br />f I L. : _ric,C) 4.---- --'1 ii/ di ..- ..--- <br />i <br />NOTES/MISCELLANEOUS , <br />I <br />, <br />Relinquished by: (Signaturg) Recen/yd B : (Signature) ;fate <br />/ ia. , • <br />1 Time <br />. c - / <br />VOAS/564 0,,np , • ' 1 .1 ilk c." 11.,' — ; • ,.__, ...I • I <br />Relinquished By: (Signature) eciirived By: (Signature) Date Time _ , <br />1 I <br />- 1 <br />4 <br /> - lv-' --' 'I • ' <br />\ Relinquished By: (Signature) <br />Dispatic.hed _I: (Signature) Date <br />Received By: (Signature) Date Time <br />Method of Shipment Description of <br />Transport Container <br />dtiher Chains-Of-Custody <br />Transported with this <br />Chain (by Serial No.) <br />Time Received for lab By: (Signature) Date Time <br />Send Lab Results to (Name): Nimy t4614Y, Ft'i FAA( ,914/1 -i-kr -) C-.4 q 6.201 (Check Office Below) Verbals Requested: Yes In .No . <br />0 SANTA PAULA <br /> T/ STOCKTON <br /> 0 VISALIA <br />TEL (805) 659-0910 <br /> TEL (209) 942-0181 <br />TEL (209) 734-9473 <br />FAX (805) 525-4172 <br /> FAX (209) 942-0423 <br />FAX (209) 738-6273 <br />FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br />WHITE: Field Copy YELLOW: Project Copy PINK: Laboratory Copy