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M mini so <br /> i • <br /> ( Advanced CHAIN OF CUSTODY RECORD <br /> GeoEnvironmental Inc. Date Page _ of—i- <br /> 4005 North Wilson Way-Stockton,California-95205-(209)467-1006-Fax(209)467-1118 <br /> Client f Project Manage <br /> LIU a&j <br /> Tests Required <br /> rPe Number <br /> 100 160 <br /> Samairs: (Sie� gnature) Invoice: <br /> Project Name AGE. <br /> &re_(Ja( - Client ❑ <br /> Sample Type � <br /> Sample Location Date Time No. of <br /> Number Description Water Air Solid Cants. Nates <br /> Comp, Grab. <br /> MLIJ -cro _ i 1,0,"1-6' A x 1XIX30 � <br /> u� oS l_06 tt 3 <br /> i <br /> e ......is e : ( �gna re eceive y: ignature Date/Time <br /> ReKnquished by: (Signature) Received by: (Signature) Date/Time <br /> Relinquished by: (Signature) Received by Mobile Laboratory for field analysis:(Signature) Date/Time <br /> Dispatched by: (Signature) Date/Time Received for Laboratory y• Date/Time <br /> r <br /> ' 0?"00 <br /> Method of Shipment: Labo►at Name <br /> ;0§6e — <br /> Special Instructions: Ihere authorize the performance of the above Indicated work. <br /> .�.._�. <br />