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CHAIN OF CUSTODY RECORD <br /> DATE r�- I �� � I PAGE � OFEnvirOnm;, <br /> PROJECT NAME C�_ OrliC � ANALYSES TO BE PERFORMED MATRIX Science 9- <br /> ADDRESS k tr)�') N c jo Engineering,Inc. <br /> ► o M U 0 .�.., <br /> A M N <br /> Q w T B T 597 Center Avenue (415)372-3637 <br /> PROJECT N0. U R E A Suite 350 <br /> N I R I Martinez,CA 94553 Fax(415)372-3790 <br /> SAMPLED BY HA I<—Je�) F X 0 E <br /> LAB NAME F R REMARKS <br /> SAMPLE # DATE TIME LOCATION MATRIX S (CONTAINER, SIZE, ETC. ) <br /> 1 <br /> I I av�7Ek ! .� ( � - 3 v o ik <br /> S� z y " q <br /> y <br /> 1 <br /> REyNQUISHED BY: (signature) attire) d t <br /> I o time TOTAL NUMBER OF CONTAINERS <br /> / ?�� ? y <br /> � ( REPORT SPECIAL SHIPMENT <br /> 2 RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4 . <br /> 5 . SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> fl, <br /> � L �� �` � .VREC'D GOOD CONDTN/COLCONFORMS TO RECORD <br />