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DATE 2L,-Zbl PAGE__L_OF / CHAIN OF CUSTODY RECORD <br /> PROJECT NAME 'r-,z kfc�t ANALYSES TO BE PERFORMED Environmental <br /> ADDRESS MATRIX <br /> _17� N fxvvcP�i:r< � i _-�-�— _� SClenCl'' dL <br /> x C _ - - = Engineering, Inc. <br /> M U O <br /> A M N <br /> PROJECT NO. f -/e - •5137 ` T B T 4I90N,WmA,,mi,• (415) 685-4053 <br /> R E A s'Il„I <br /> 5�� t. (x Ji ��c �� V X R I c „„a,cAvasza <br /> SAMPLED BY <br /> -- <br /> LAB NAME SPlo%oA"-( ca. � F R <br /> SAMPLE # DATE TIME LOCATION S REMARKS <br /> ' MATRIX (CONTAINER, SIZE, ETC. ) <br /> 52 -L z 2:21 ►l.ucl� )(' Q„ Q_J 16 ' <br /> Sol 1 <br /> base <br /> RELINQUISHED BY: (s,ig ature) E EIVED ; (signature) ate time <br /> S TOTAL NUMBER OF CONTAINERS <br /> 2 . RESULTS TO: REQUIREMENTSMENT <br /> 3 . <br /> 5. <br /> SAMPLE RECEIPT <br /> 'tSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> a- 6,er,5c_ <br /> 5520 <br /> REC'D GOOD CONDTN/COLD <br /> CONFORMS TO RECORD <br />