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i i i i i =� ok' j ApW i i i i i i 4r <br /> 4r <br /> DATE ,., 1- w, PAGE� OF ('IIAI11 OF CUSTODYRECORD <br /> PROJECT NAME >~acj OL" r �AITALYSES TO BE PERFORMED MATRI)r Denah Group <br /> ADDRESS 174 o 4J N C <br /> ]Tnek*e„� <_q 1•� a �` A M 1850 Gateway Blvd,Suite 110 Tel (925)602 2333 <br /> Y <br /> PROJECT NO. :5B A 687 125 <br /> Concord,California 94520 Fax (925) a <br /> � l 3 00 '° �} ;, �-i <br /> SAMPLED BY �� J h <br /> X O $ <br /> LAB <br /> NAME M, Oe ,,,,Q �, y F R REMARKS <br /> (` M ` ��' S (CONTAINER, SIZE, ETC. ) <br /> SAMPLE # DATE TIME LOCATIOt7 .ri r1 i MATRIX <br /> L71- f 1 0'74b n <br /> J ZT <br /> rrl�� 1 rx. <br /> ro..r. - <br /> - <br /> 23 x <br /> X — �? <br /> REY T5HE ( ignalture) /�dE LVED BY: ( ature) d�2 ` ti , j TOTAL NUMBER OF CONTAINERS <br /> L REPORT SPECIAL SHIPMENT <br /> 2 • RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4 . <br /> 5 . SAMPLE RECEIPT <br /> INS RUCTIONS TO LAA RATORY (handling, analyses, storage, etc. ) CHAIN OF CUSTODY SEALS <br /> REC{D GOOD CONDTN/COLD <br /> CONFORMS TO RECORD <br /> ell, +we <br />