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DATE-// $1 PAGEOF �L CHAIN OF CUSTODY RECORD r <br /> PROJECT NAME ir ANALYSES TO BE PERFORMED Environmental <br /> ADDRESS °U MATRIX ® Science & <br /> M u o Engineerinsg,Inc. <br /> PROJECT NO. C, �//i 1S%5 T M N <br /> B T <br /> 597- <br /> SAMPLED <br /> 9 SAMPLED BY / �y ! .0„/, _ \ I R I <br /> LAB NAME . it. W Xp Ewty�z3�9o— <br /> SAMPLE # DATE TIME LOCATION F RREMARKS <br /> MATRIX S (CONTAINER, SIZE, ETC. ) <br /> I S o(o ' CAV, l1011/ <br /> 3z <br /> q r <br /> 9 133,— / <br /> RELINQU1;SHEb BY: (signature) I nature <br /> j' ) date time i TOTAL NUMBER OF CONTAINS <br /> 2 ' REPORT SPECIAL SHIPMENT <br /> RESULTS TO: REQUIREMENTS <br /> 3 . aa <br /> 4 . <br /> 5. <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, stora a SAMPLE RECEIPT <br /> (moi f ){- C-CY ��'i�1 bV St� (lJr^L �c"G� ��,�1 ��I_P ) CHAIN OF CUSTODY SEALS <br /> U��l l D S REC'D GOOD CONDTN/COLD <br /> �1 CONFORMS TO RECORD <br />