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. CHAIN OF CUSTODY RECORD ANALYSIS REQUEST <br /> 5500 Boscell Common Fremont CA 94538 el 510 490-8571 Fax 510 490-8572 <br /> 0ANSIME Project Manager G e Pj Bili to <br /> E N V I R O N M E N T A L Client Name Company <br /> LABORATORIES, INC Address Address <br /> City, State ZIP An. rAtl City, State ZIP ` - <br /> Phone Phone <br /> Date //7/Qq Fax Fax <br /> Page 2 of j.— <br /> Laboratory at,5,.4e Env Protect Name cc,U 1-6 o Qd P 0 No <br /> Lab Number 2 e of Project Number 3 in 0 <br /> Analy is Requested <br /> LO <br /> 0 g <br /> M ao \ ` <br /> Cd L C N V G <br /> d ? Q O <br /> Sample IdentihcalionDate Sampled Time Sampled Matrix (Ai c m a a ° Remarks <br /> Z <br /> /S3o HV 2Fa46- Oq <br /> _ �/ Z z <br /> w 5 ss� -{o X 3 <br /> y& s s< /6/� 6/6 -Il Z <br /> 57' 9 // �` /L 3U4 -12 y y Y, '2- <br /> Initials <br /> Initials Printed Name Signature Date Total Containers <br /> MY M.C�,t ek -Q-, tart Time Received Intact <br /> ;, r e4 f k Stop Time Received Cold <br /> Hours Custody Seals <br /> Client Sign-off <br /> White Copy -Admin/Lab Yellow - Mobile Lab Pink - Client <br />