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• FGL ENVIRONMENTAL CHAIN -OF -CUSTODY RECORD LAB PROJECT <br />(See Reverse for Instructions) NO. <br />PROJECT NAME \M`l`,AQ F L -V SAMPLERS e-ZIS- 000-:ro"-4 <br />(PRINT) <br />PROJECT NUMBER Ck-EX • L;: -D <br />(SIGN) <br />RECORDER <br />(SIGN) <br />SAMPLE CONTAINER <br />DESCRIPTION CODES <br />04o-ml VOA Vial <br />B. Glass Liter E. Brass Tube <br />C. Plastic 500 -ml F. Other <br />D. Plastic Liter <br />SAMPLE DESCRIPTION CODES <br />A. Ground Water F. Oil <br />B. Surface Water G. Waste <br />&;>Leachate H. Blank/Spike <br />D. Rinseate 1. Other <br />E. Soil/Sediment <br />TAT CODES <br />t. Standar <br />2. 5 Day <br />3. 60 Hour <br />4. Other <br />11111111111111ATE <br />TIME <br />SAMPLE ID <br />E <br />N <br />NUMBER OF <br />CONTAINERS <br />AND <br />PRESERVATION <br />2a <br />ANALYSIS <br />REQUESTED <br />0 <br />9 <br />E <br />E <br />9 E <br />2 V <br />n <br />2- <br />E <br />N <br /><�� <br />0 <br />> <br />z <br />NOTES <br />LABORATORY USE ONLY <br />SAMPLE <br />ASSIGNED CONDITION <br />BOTTLE UPON <br />NUMBERS RECEIPT NOTES <br />-911111a-7 <br />w <br />a <br />CX <br />X I <br />oli.-o <br />FT <br />NOTES / MISCELLANEOUS <br />Relinquished by: (Signature) <br />Received By: (Signature) Date <br />Time <br />Relinquished By: (Signature) <br />Received By: ure) Date <br />Time <br />Relinquished By: ( tfature) <br />RECc-ei d By: (Signature) Date <br />Time <br />Method of Shipment <br />AA,t-\r <br />Description of <br />Transport Container <br />Other Chains -Of -Custody <br />Transported with this <br />Chain (by Serial No.) <br />Dispatched By: (Signature) Date <br />Time <br />Received for lab By: (Signature) Date <br />Time <br />Send Lab Results to (Name): <br />(Check Office Below) VerbalI(Aequested: Yes El No E'-- <br />❑ SANTA PAULA R-STOCKTON El VISALIA <br />TEL (805) 659-0910 TEL (209) 942-0181 TEL (209) 734-9473 <br />FAX (805) 525-4172 FAX (209) 942-0423 FAX (209) 738-6273 <br />FGL ENVIRONMENTAL LABORATORY • 2500 STAGECOACH ROAD o STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br />WHITE: Field Copy YELLOW: Project Copy PINK: laboratory Copy <br />