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FGL ENVIRONMENTAL CHAIN—OF—CUSTODY RECORD <br />(See Reverse for Instructions) <br />LAB PROJECT <br />NO <br /> <br />PROJECT NAME <br />PROJECT NUMBER <br />MI; IV iLANQ hcl--e-41, ilf-s SAMPLERS ki Mel' • SAMPLE CONTAINER <br />DESCRIPTION <br />40 ml VOA Vial <br />-01giT_Iter'—' <br />Plastic 500-ml <br />Plastic Liter <br />Brass <br />Other <br />CODES <br />Tube <br />SAMPLE DESCRIPTION <br />Ground Water -- <br />Surface Water <br />Leachate <br />Rinseate <br />Soil/Sediment <br />CODES <br />Oil <br />Waste <br />Blank/Spike <br />Other <br />TAT CODES <br />Standarsl — <br />5 Day <br />3_ 60 Hour <br />4. Other <br />(PRINT) <br />/ i I . ;:./_ ( <br />RECORDER <br />(SIGN) , <br />(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 tor Method Requested Sample Stored at 4°C (Check) No VOA Headspace (Check) NOTES - NOTES <br />LABORATORY USE ONLY <br />(-6 <br />Ci'l, <br />'5 ASSIGNED <br />BOTTLE <br />NUMBERS <br />SAMPLE <br />CONDITION <br />UPON <br />RECEIPT NOTES <br />.,_. <br />%' 5 <br />0 <br />2 . <br />— <br />.J <br />6-Li.L6 iC).4, 46 1 4 v4,-;4 t e , !ix" Buckei tch v Licic,k6s '' v <br />6 c4q3 10!60 V-1 24) ‘,Q& u A/ Mucx tfocA vi ..-- ,- -- --- --- <br />i <br />Ak 1, 4. <br />- <br />NOTES/ MISCELLANEOUS <br />9' WA/ 4x:A (IV 1 ..-- IP <br />i <br />Rel nquished by: (Signature) <br />74-11." . • _, Received By: (Signature) Date Time <br />Relinquished By (Signature) Received By: (Signature) Date Time <br />Relinquished By: (Signature) Received By: (Signature) Date Time <br />Method of Shipment Description of <br />Transport Container <br />Other Chains-Of-Custody <br />Transported with this <br />Chain (by Serial No.) <br />Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br />Send Lab Results to (Name): MAKI ME-M5 ru f3L4 ,-.447-1 ‹.34..ilci, v72_01 (Check Office Below) Verbals Requested: Yes 1.--No LI <br />E SANTA PAULA <br /> E VISALIA <br />TEL (805) 659-0910 <br /> TEL (209) 942-0181 <br /> <br />TEL (209) 734-9473 <br />FAX (805) 525-4172 <br /> FAX (209) 942-0423 <br /> <br />FAX (209) 738-6273 <br />FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br />WHI IF Field Cop) 1 ELLOW. Project Cop) PINK: Laborator)