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Department of Toxic Substances Control <br />Environmental Chemistry Lab - Berkeley <br />700 Heinz Ave. Suite 150, Berkeley CA 94710 <br />Phone: (510) 540-3111 Email: smoffCdtsc.ca.gov <br />Sample Transport Record Sheet <br />Autharization#: 10 fil C)1QPj <br />SiteName: QC• <br />Site Address: 24353 <br />sh or Records included:ARF �SAR <br />Sample Receipt Sheet <br />ECL No. Collector ID. Sample Type Analysis Request Remark (see note) <br />N A ki um a C titncdlp OYL <br />j %b ^� <br />�� 1Q C <br />Note: for remark;: OSC - Original Sample Container; SS - Split Sample: a - Aliquot; F - Fractionated Sample <br />Released For Transport by: <br />Name: j..�►1)�ynq Gj%&(i Signature: Dale,Mme: i �� �� <br />Tracking Number. -J. - ..3q 7a 2 bj'51% //�� n t n4Confirmation Nt(unber. ✓�, /� ` yyAA j Ch <br />Name oFLahoratory Sample(s) Transported to: AAV a<InCf � midi—ay {,MWS �'tl "`�eSj,ocation (city]: 1 Q M'le%lt )AIII 1 4I { <br />vC7'— <br />Transported by: (circle one) Fed;_x Other if other, specify: <br />Reminder: Include copy of transport bill in authorization folder. <br />Comments and/or :additional TrackinglNlvltiple Packing Shipment (NIPS) 0: <br />DCN: 07.0072.00—Revision 3_0911712020_Approved by Quality Management Officer Page 1 of 1 <br />iMV-4 <br />1z►VA.q <br />Page 6 of 33 <br />