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CHAIN OF CUSTODY RECORD 1 q 6 2 <br /> ERM-West, Inc. S�I ,��p�� <br />� of i <br /> 1777 Botelho Drive, Suite 260 • Walnut Creek, CA• 94596• (510) 946-0455 • FAX (510) 946-9968 <br /> C� fc, I:3 Pa e <br /> PROJECT# iPROJECT NAME REQUESTED PARAMETERS <br /> MATRIX <br /> SAMPLER (PRINT NAME) (SIGNATURE) <br /> �ri S Au I <br /> 4 <br /> RECEIVING LABORATORY <br /> 1,;4 Gk C '. e- <br /> D <br /> a SAMPLING W?fn SAMPLING • ,�{ <br /> SAMPLE I d DATE TIME METHOD ay yr VOLUME ` + <br /> D� ,ZSr+r L � Oc <br /> 3 � x D <br /> . � <br /> RELINOUISHED Y(SIGN E) DATE TIME RECE BY DATE TIME FIELD REMARKS <br /> REU ED ! ATURE) DATE TIME RECEIVED BY *AEd <br /> TIME X <br /> z1 I�3 <br /> RELINQUISHED BY(SIGNATURE) DATE TIME CEIVED BY DATE TIME <br /> ,cry I� <br /> REMARKS ON SAMPLE RECEIPT ERM REMARKS r SEND REPORT TO <br /> ❑ BOTTLE INTACT ❑ CUSTODY SEALS ❑ CHILLED (�U•i l {¢h <br /> ❑ PRESERV ❑ SEALS INTACT ❑ SEE REMARKS <br /> i n nv WRav 0, Rr IP _ PINMrbRA1,F"A NA(:1tW f;1kWR011 F <br />