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� CHAIN OF CUSTODY RECORD <br /> DATE^�r�,i� t/�. � PAGE_. � - 0V Environmental <br /> PROJECT NAME 1 ANALYSES TO BE PERFORMED MATRIX � Science & <br /> cl <br /> ADDRESS �E�r..�, r ` M u o Engineering, hic <br /> A M N (415) 685-4053 <br /> T BT 404U Ndwn Avum, <br /> I PROJECT N0. l92 C' _ E A suiicl <br /> }? I R I Cunaird,CA 94520 Fax(415)etl5�s23 <br /> SAMPLED BY r� X O N <br /> LAB NAME F R REMARKS <br /> SAMPLE DATE TIME IACATION MATRIX S (CONTAINER, SIZE, ETC. ) <br /> p0/11' (If s6c,�Z= 1 1 101, <br /> 1 1 <br /> Z <br /> B <br /> RELINQu H X: (sicature) T�011 <br /> B sicre) date time TOTAL NUMBER OF CONTAINERS <br /> i. .Z ' <br /> REPORT SPECIAL SHIPMENT <br /> 1, , :, �• RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4 . <br /> 5 , SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) ; CHAIN OF CUSTODY SEALS <br /> RECD GOOD CONDTN/COLD <br /> [CONFORMS TO RECORD <br />