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OW Nti#L 01L UOMPAN Y �HAIN OF CU TODY RECORD Date: 004 <br /> Serial No: &� Pae 1 of 1 <br /> Site Address: Shell Pipeline,Mountain IIouse Analysis Require LAB: Kiff Analytical <br /> Tracy,CA CHECK ONE(1)BOX ONLY Cr lNn1RN AROUND TIME <br /> WIC#: " <br /> GW Monitoring 0 4461 24 hours 0 <br /> 'd <br /> Shea Engineer. Jeff Goold U site Investigation X 4441 48 hours 0 <br /> Consultant Name&Address: Phone: 925.426.2600 <br /> u Soil Classify/Disposal 0 4442 15 days X (Nemo <br /> Clayton Grp Services Fax: 925.426.0106 6 .o Water Classify Disposal O 4443 other 0 — <br /> 6920 Koll Center Pkwy,Ste 216,Pleasanton CA 94566 A ro SoiRAir Rem.or Syn.O&M 0 4452 <br /> Consultant Contact: Mike Ilurd/Craig Pelletier t7 Water Rem.or Syso a M 0 4453 <br /> Comments: 0 <br /> oOdmr 0 <br /> Sampled by: CraigPellelier 000 UST Agency: <br /> Printed Name: Craig Pelletier ul w <br /> No.of x x Sample Condition/ <br /> Sample In Date Sludge Soil Water Air conts. w i,- Material Description Comments <br /> MW-I 8/IO 004 X 5 X X X Groundwater �� <br /> MW-2 8/1D 004 X 5 X X X Groundwater y <br /> MW-3 8/I 004 X 5 X X X Groundwater <br /> i MW-4 8/1 004 X 5 X X X Groundwater O( <br /> MW-5 8/1C 004 X 5 X X X Groundwater <br /> MW-6 an 004 X 5 X I X I X Groundwater oo <br /> Relin sh ( gra re) - Printed Name: Date:O i) it Received(signature) Printed Name: ate: <br /> Craig Pelletier Time: �. Time: <br /> Relinquish y(signature) Printed Name: Dale: Received ature) Printed Name: Urate: <br /> Relinquished By(signature Printed Name: Date: ed(signature) 4 <br /> R Printed Name: Dale:ay//Q <br /> nue: �/ S T Ime: <br /> THE LABORATORY MUST PROVIDE A COPY OF THIS Cl`lAlN-0FeuusT DY TH INVOICE AND RESULTS <br />