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fewl 1 <br /> DATE PAGE / OF / CHAIN OF CUSTODY RECORD <br /> Environmental <br /> PROJECT NAME SCC illi ANALYSES TO BE PERFORMED MATRIX I Science & <br /> ADDRESS-3 35 r*, (yd, def �e N C _ Engineering,Inc <br /> MU 0 F CI[CCp9 Gmp.Y <br /> A M N <br /> /_may��, `�O T B T 5040 j odson Avenue Phone(510)685-4053 <br /> PROJECT NO. "'�� `f _ _ R E A <br /> SAMPLED BY GL IyL(h S T � V X R I Cnnaud CA 9452{] Fax(510)685-5323 <br /> 0 19LAB NAME F R REMARKS <br /> SAMPLE # DATE TIME LOCATION t�'- MATRIX S (CONTAINER, SIZE, ETC. ) <br /> well <br /> 2 I P q11 X <br /> q <br /> R���,BY,:,(signature) C IVED B signature} date_ time - 9TOTAL NUMBER OF CONTAINERS <br /> albREPORT SPECIAL SHIPMENT <br /> 2 RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4. <br /> 5. SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> REC°D GOOD CONDTH/COLD <br /> CONFORMS TO RECORD <br /> E <br />