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IRUPPi' '. � � � = M = -9 M M M M = M <br /> i I CHAIN OF CUSTODY RECORD <br /> DATE PAGE f OF Environmental <br /> PRO ECT NAME 77-7 XXe-L ANALYSES To BE PERFORMED MATRIX Science & <br /> ADDRESS- /L? rtLA4ut � N C ,��`.--- Engineering, 111C <br /> M U 0 .MCOMP Com., <br /> A M N <br /> 4090 Nilsen Avtnw Phone(510)685-4053 <br /> PROJECT NO. q ` 5`I R E A su,te) <br /> SAMPLED BY IR N Conoird,CA94520 Fax(510)685-5323 <br /> LAB NAME Cam E"rr ac�� \ <br /> F R REMARKS <br /> SAMPLE DATE TIME LOCATIONMATRIX S (CONTAINER, SIZE, ETC. ) <br /> .` <br /> PLO— <br /> J 1z z /s/o <br /> ?� Mw- 3 zgm <br /> <' W- �C <br /> N) -4 <br /> ,b <br /> S+ <br /> Y <br /> U'LlnU7 <br /> Y: (signature) RECEIVED BY: (si nature) date time / � TOTAL NUMBER OF CONTAINERS <br /> 'Gl !a n? I SD <br /> REPORT SPECIAL SHIPMENT <br /> RESULTS TO: REQUIREMENTS <br /> 3 . to- [/h <br /> 4 . <br /> 5' SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> i <br /> RECD GOOD CONDTN/COLD <br /> CONFORMS TO RECORD <br />