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i <br /> INA 5� <br /> DATE PAGE OF CHAIN OF CUSTODY RECORD <br /> Environmental <br /> PROJECT NAME I-o4/ ANALYSES TO BE PERFORMED MATRIX Science & <br /> ADDRESS �SCDj, �,�r- oa� N C Engineering,Inc. <br /> C M U O <br /> +Oncoe►rnmcan, <br /> A M N (415)685-4053 <br /> r T B T 4M Nilson Avenue <br /> PROJECT NO. 0/0 QS0 R E A Suite <br /> IR I Concord,CA 94520 FAX(415)685 51:3 <br /> SAMPLED BY New'l t X <br /> LAB NAME Gu r f S �- -75—mol/n-5 n F R REMARKS <br /> SAMPLE # DATE TIME LOCATION I IMATRIX S (CONTAINER, SIZE, ETC. ) <br /> Iq <br /> W- TtTZad, 3VVIOIreserv�'✓� <br /> JV <br /> AM <br /> ,► 10 '/ I <br /> S <br /> > 1� D <br /> RELI Q IS EBY: (s gnature) RECEI (signature) date time TOTAL NUMBER OF CONTAINERS <br /> 1' 5 4 1730 REPORT SPECIAL SHIPMENT <br /> 2. RESULTS TO: <br /> ' REQUIREMENTS <br /> 3. Su S)a n <br /> 14. <br /> �l CK Cr YY <br /> 5. SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handlin , analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> REC'D GOOD CONDTN/COLD <br /> �� �`� CONFORMS TO RECjW <br />