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l• emir k�m WWI` 0 <br /> ' I• few <br /> CHAIN OF CUSTODY RECORD <br /> Advanced <br /> Date � /9 Z Page of�--- <br /> GeoEnvironmental, Inc <br /> 837 Shaw Road -Stockton, Califorma 95215 - (209) 467-1006 Fax (209) 467-1118 <br /> Proplat Manage 6�. <br /> Tests RequiredClient s 'LSSI b� t� , , , of I�� Lt�4 <br /> Phone Number <br /> Samplers (Signature) Invoice <br /> AGE ❑ <br /> // } ` Client <br /> Protect Name �{. ct J,���� - <br /> Sample Type No of �` <br /> Sample Location Date Time Water Solid , Notes <br /> Number Description camp Grob Air Conts (� <br /> ✓ i Olt- <br /> Irk it <br /> QA N A PPROIgUA-12 <br /> HWI AD A ABS CONTAINJIM <br /> I;itB.,....� <br /> O� WIF17Y1tf) 07'FtirA <br /> P ES A ON <br /> etre tgneture Owsfrrme <br /> e rn u�s e y ( rgnature <br /> IV DatelTlma <br /> Relinquished by (Signa ute) Received y (Signature) ✓l - , <br /> Rehnquished by (Signature) Received by Mobile laboratory f it Id nety is (Signature) <br /> DatelTime <br /> RLCrD LED& rato, b Date/Time <br /> Dispatched by (Signature) DatelTlme y y <br /> Laboratory Name / <br /> Method of Shipment /0(- 4! 1 <br /> 1 hereby authorize the performance or the above indicated work j <br /> Special instructions <br />