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CHAIN OF CUSTODY RECORD <br /> ERM-West, Inc. �U 1963 �. <br /> I is- <br /> 1777 Botelho Drive, Suite 260 • Walnut Creek, CA• 94596 • (510) 946-0455 • FAX (510) 946-9968 I Page �� Of c-,C ,.. <br /> PROJECT# PROJECT NAME REQUESTED PARAMETERS C: <br /> z <br /> ,u <br /> 9 71 ov r 5 5-ke-kf�� MATRIX <br /> SAMPLER (PRINT NAME) (SIGNATURE) , <br /> tiedtL3 s <br /> ��., �-It,%,S ,{y1 <br /> RECEIVING LABORAT RY �� •� r <br /> SAMPLE I D DATE TIME a dL <br /> SAMPLING CL Erww z SAMPLING M <br /> O 0 METHOD a U? VOLUME <br /> WJ& ver44 K ksC x x <br /> r 1630 <br /> RELINQUISHED BY(SIGNATURE) DATE TIME RECEIVED BY DATE TIME FIELD REMARKS <br /> ate 1 6qa <br /> r4a� <br /> RELIN UI BY(SIGNATURE) DATE TIME EIVED BY DATE TIME <br /> I`'(Lt� b�y 6 Ih I S <br /> RELIN UISHE Y(SIGNATURE) DATE TIME UCEIVED BY DATE TIME <br /> REMARKS ON SAMPLE RECEIPT ERM REMARKS SEND REPORT TO <br /> ❑ BOTTLE INTACT ❑ CUSTODY SEALS ❑ CHILLED j- I! Qz� ; rc,vx <br /> ❑ PFIESEFIU& ❑ SEALS INTACT ❑ SEE REMARKS <br /> -I AlWCIRAM MARYOW m= PIMATARMAIVAiM MF 00rW11 r-M <br />