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Ir L Advanced CHAIN OF CUSTODY RECORD <br /> 1 y <br /> f7 <br /> Date_� �� Page —t— of <br /> GeoEnvironmental, Inc. <br /> 4 <br /> 4005 North Wilson Way Stockton,California-95205 (209)467 1006-Fax(209)467-1118 <br /> Client � �.1te�- <br /> Project Manager Ll �1 �. � G C T{ !<� ��,� �� Tests Required <br /> Phone Number <br /> Samplers (Signature Invoice <br /> AGE <br /> Project Name �/� P Client Q' <br /> Sample Type <br /> Sample Location Date Time No of <br /> Number Description Water Air Solid Conts Notes <br /> Comp Grab <br /> e m ed, y ignature) Receivedy (Signature) S DatelT{me <br /> Relinquished b (Signature) y/ 4 - "`-" j G <br /> q Y Rac ry try (Signature) � t1 ({ at im� � L) <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis ( ignat Datel7ime <br /> Dispatched by (Signature) Date/Time Received for Laboratory by DatelTime <br /> Method of Shipment Laboratgry�N�me <br /> 60 - HA <br /> Special Instructions I hereby authorize the perforr�itance of the above indicated work <br />