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® % ® ® Lam] ® ® Idw ® Am Am M <br />� 1 <br /> CHAIN OF CUSTODY RECORD <br /> DATE PAGE 1 OF_� Environmental <br /> PROJECT NAME ANALYSES TO BE PERFORMED MATRIX Science & <br /> ADDRESS,��3$'�C ( �p N C _ Engineering,Inc <br /> t A M N <br /> T B T4(1411 NvNm Avrnue Phone(510)6854053 <br /> PROJECT NO. C0j;L5 Da _._ R E A Suitr) <br /> SAMPLED BY X R I Cona).d'CA 94520 Fax 010)685-$323 <br /> LAB NAME Mf,(Pft9W1 F R REMARKS <br /> ` <br /> SAMPLE # DATE TIME LOCATION MATRIX S (CONTAINER, SIZE, ETC. ) <br /> *Ar, G630 5V'X9M I 0 - - <br /> WS31% 1600 <br /> y 72453 <br /> 3 � � <br /> 31%ih, I?oo 3 I 72454 <br /> U 1 -3N 6 <br /> Tltp 1� 3y --- �` r i� a --- 11455 <br /> f <br /> 71456 I <br /> I <br /> 71457 <br /> 72450 <br /> I <br /> R I QUI ED BY ature) IVE ems = i%at7re) da pe time TOTAL NUMBER OF CONTAINERS <br /> o <br /> �� /� REPORT SPECIAL SHIPMENT <br /> 2. RESULTS TO; REQUIREMENTS <br /> 3 . / die/ e <br /> 4. <br /> 06 <br /> S• SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> RW r REC°D GOOD CONDTH/COLD <br /> fl CONFORMS TO RECORD <br /> GOOD CONDMON-4- APPROPRIATE <br /> HEAD SPACE ABSENT CONTAl1 LL <br />