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i <br /> AM-lor LIMJRV( OW LOW LNWJ AW �W wft hm M <br /> CHAIN OF CUSTODY RECORD <br /> SATE 7 S PAGE�OF Environmental <br /> PROJECT NAME ANALYSES TO BE PERFORMED MATRIX 4 Science & <br /> ADDRESS 3s`35 F 6k-&"&" LE( N C �_ _ Engineering,Inc <br /> 3 '•' M U 0 A MCCORP*DRW, <br /> A B N 4090 Nelson Avenue Phone(510)685-4053 <br /> PROJECT NO. Lo 5z 5� " R A SL°+C j <br /> X R I Conaor3 CA 94520 Fax(510)685-5323 <br /> SAMPLED BY <br /> LAB NAME T -� }` F R REMARKS <br /> SAMPLE # DATE TIME LOCATION MATRIX S (CONTAINER, SIZE, ETC. ) <br /> (D waw �' -,1,(: vo A-s <br /> E <br /> .RELLbIQ <br /> i <br /> U H BY: (signature) RE E VED BYE#ig tura) Safe time <br /> TOTAL NUMBER OF CONTAINERS <br /> ff REPORT SPECIAL SHIPMENT <br /> • RESULTS TO: REQUIREMENTS <br /> 3 . <br /> 4. <br /> 5• S PLE RECEIPT <br /> INSTRUCTIONS TO LABORATORY (handling, analyses, storage, etc. ) : CHAIN OF CUSTODY SEALS <br /> RECD GOOD CONDTN/COLD <br /> CONFORMS TO RECORD <br /> E <br />