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I� CHAIN OF CUSTODOECORD <br /> Advanced QZ Datel�Z� �s Page —L of <br /> GeoEnvironmentai, Inc <br /> 837 Shaw Road- Stockton, California-95215- (209)467-1006- Fax (209) 467-1118 <br /> Client �� �� . Project Manager Tests Required <br /> l/ ll4p-' 4 <br /> Phone Number it <br /> vue-1 <br /> Samplers (Signature) Invoice <br /> AGE �< <br /> Project Name Client ❑ <br /> Ch,67,21,"4 /40, <br /> f� � <br /> Sample Location Sample Type Date Time Water Solid No of Notes <br /> Number Description Air Corns <br /> Comp Grab <br /> 4 630 f <br /> ,,3 <br /> 101;5 %1-,- -Z <br /> � <br /> e inquis e y J>i?nature) eceive y TTtgnature � Date/Time <br /> Relinquished by (5ignatur ) Received by (Signature) DatelTime <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis (Signature) Daterrime <br /> Dispatched by (Signature) Daterrime Receiv r bora"! by atelTime <br /> Method of Shipment Laboratory Names_ <br /> Special Instructions ll +� �� I hereby authorize the performance of the above Indicated work <br />