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14W 40% L4w Am MW too] I'm" I=d M <br /> I j PAGE `� OF CHAIN OF CUSTODY RECORD `3�"Z� L6_5'Ek 1w <br /> DATE S- r � <br /> PROJECT NAME c�n ANALYSES TO BE PERFORMED MATRIX Ir Environmental <br /> Science & <br /> ADDRESS 35 S LmVee 'Zj N C f , Engineering, I3ic <br /> ' 1 C ��t-�'o0i rl y, � M U 0 A CILCORV CtrR y <br /> TT 1 IA M N <br /> PROJECT NO. T B T 4090 N(Icon Avenue Phone(510)685 4053 <br /> surtc.) <br /> to SAMPLED BY ,�, (,�J ,A � <br /> X R Concord CA 94520 Fax(510)685-5323 <br /> LAB NAME bi) O E <br /> F R REMARKS <br /> SAMPLE # DATE TIME LOCATION � � MATRIX S (CONTAINER, SIZE, ETC. ) <br /> q56- of <br /> ------------- <br /> r 5 � 53� <br /> 4 r <br /> 3 T ,�-s�s 1153s it y 1 <br /> �1�0 N-.S-95 D�.�9 11 j Naldl ' a 1 533 � <br /> t <br /> t <br /> r <br /> 5534 <br /> It <br /> ' 51535 <br /> H � <br /> r r <br /> RE S EpqY: (signature) RECEIVED BY: ' <br /> � (signature) date time � TOTAL NUMBER OF CONTAINERS <br /> 16115 q ys'c <br /> 2. REPORT SPECIAL SHIPMENT <br /> RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4 . CA CDP 5ft:re <br /> 5. <br /> SAMPLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> REC°D GOOD CONDTN/COLD <br /> 0 <br /> O�iG irm' ;MIR CONFORMS TO RECORD <br /> coot C01���l � <br /> HEAD SPACEABSffa C�1i <br />