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ERM-West, Inc CHAIN OF CUSTODY RECORD � Zg63 �� <br /> X 777 Botelho Drive, Suite 260 • Walnut Creels, CA • 94596• (510) 946-0455 • FAX (510) 946-9968`1 r I Z�tc <br /> �r� ge <br /> PROJECT# a a Of nC <br /> PROJECT NAME <br /> Z9 FiC cw /(u s k io" MATRIX REQUESTED PARAMETERS <br /> SAMPLER {PRINT NAME) (SIGNATURE) <br /> �,� 1 ' <br /> 'De <br /> L blr;s ,� <br /> t • <br /> RECEIVING LA80RAT RY <br /> Irr <br /> • rY r <br /> SAMPLE I D DATE TIME � SAMPLING �? �= SAMPLING J� L v 1� ~ <br /> v0 METHOD VOLUME <br /> ca <br /> 1630 <br /> RELINQUISHED BY(SIGNATURE) DATE TIME RECEIVED BY DATE TIME <br /> FIELD REMARKS <br /> RELIN UI BY(SIGNATURE) DATE TIME r /tot <br /> IVED BY DATE TIME <br /> Iu <br /> 6`( r b�y�b <br /> RELIN DISH Y(SIGNATURE) DATE TIME CEIVED BY DATE TIME <br /> REMARKS ON SAMPLE RECEIPT ERM REMARKS <br /> ❑ BOTTLE INTACT ❑ CUSTODY SEALS ❑ CHILLED SEND REPORT TO <br /> ❑ PR VED ❑ SEALS INTACT ❑ SEE REMARKS <br />