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0 CHAIN OF CUSADY RECORD ' <br /> ERM-West, Inc® 1 <br /> 116 <br /> 177 Iho Drive Suite 260 a Walnut Creek CA ® 94596 • 510 946-0455 © FAX 510 946-9968 ` Page 3 of 3 <br /> 7 Bote ( } ( ) <br /> PROJECT# PROJECT NAME MATRIX REQUESTED PARAMETERS <br /> 337es0 <br /> SAMPLER (PRINT NAME) (SIGNATURE) <br /> RECEIVING LABORAT <br /> a SAMPLING S�MPLING <br /> �w <br /> SAMPLElD DATE TIME p METHOD ¢� �? VOLUME <br /> CL <br /> J� <br /> �{�- 3 •33 !l I#' �I�� a X_ X Q <br /> �6 �-I ���� � Y , x � <br /> ELINQUISHED BY(SIGNATURE) DATE TIME RECEIVED BY DATE I TIME FIELD REMARKS <br /> RELI IHED BY) NATURE} ATE TIME <br /> S013Y <br /> RELINQUISHED BY(SIGNATURE) _ DATE TIME RECEIVED BY DATE TIME <br /> & <br /> REMARKS ON SAMPLE RECEIPT ERM REMARKS S DRE ORT TO <br /> ❑ BOTTLE INTACT ❑ CUSTODY SEALSCHILLED <br /> ❑ PRESERVED [IC <br /> SEALS INTACT `SEE REMARKS <br /> WHITE-LABORATORY COPY CANARY-FIELD COPY PINK-DATABASE MANAGER GOLD-PROJECT FILE <br />