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GORE-SORBER® Screening Survey Chain of Custody <br /> ' For W L Gore&Associates use only <br /> Production Order# 4 <br /> ' s W L. Gore & Associates, Inc., Survey Products Group <br /> 100 Chesapeake Boulevard• Elkton, Maryland 21921 • Tel (410)392-7600•Fax(410)506-4780 <br /> Instructions Customer must complete ALL shaded cells <br /> Customer Name GEOLOGICAL TECHNICS, INC Site Name UNKNOWN <br /> 7b C1C.i <br /> Address 1101 7TH STREET Site Address CA <br /> b'� w tiSCw�l <br /> MODESTO CA 95354 ► �-i�Ct G� <br /> Project Manager <br /> Phone (209)522-4119 Customer Project No p 1 , 2— <br /> FAX <br /> FAX Customer P O # 91246J Quote# 212503 <br /> Serial#of Modules Shipped #of Modules for Installation 20 #of Trip Blanks 2 <br /> #402117 - #402130 # - # Total Modules Shipped 22 Pieces <br /> #402138 - #402145 # # Total Modules Received L 2 Pieces <br /> # - # # - # Total Modules Installed 2= Pieces <br /> # # # - # Serial#of Trip Blanks(Client Decides) # <br /> # # # - # # 11Q�1Lt Y # # <br /> # # - # # L(p�1 Ll # # <br /> # # # # # # <br /> repared By # # # <br /> enfied By # # # <br /> Installation Performed X Installation Method(s) (circle those that apply) <br /> ame(please print) Scs,e wr p noz,G LtL o Slide Hammer ammer Dnll Auger <br /> ompany/Affiliation G Lbs-,C tc-�kt- Tn't fin.- Other <br /> Installation Start Date and Time S I Z 3 / 0 Z 6- 55 PM <br /> nstallation Complete Date and Time 1 Z3 / �/ C C: AM 'PM <br /> etrieval Performed By Total Modules Retrieved 2_c Pieces <br /> ame(please print) _ ,,1��FP! Q ' Total Modules Lost in Field ¢� Pieces <br /> ompany/Affiliation I_ C��2itLL t.(-1<L T`��tk+��LS Wc— Total Unused Modules Returned �- Pieces <br /> etrieval Start Date and Time (� I (, l DZ j PM <br /> etrieval Complete Date and Time (� 1 13 / v � : PM <br /> elinquished By Date Time Received B G L Date Time <br /> Affiliation W L Gore&Associates, e � la Affiliation ' 5/23/01 0730 <br /> L elinquished By Date Time Received By Date Time <br /> L ffiliation ���� i'�— }Lrn�cc- 3l0Z 3;, Affiliation <br /> a <br /> nquished By Date Time Received By / Date Time <br /> iliation Affiliation W L Gdre& Associateg, Inc z/-19 /a 3 <br /> ' GORE-SORBER 0 Screening Survey is a registered service mark of W L Gore &Associates Inc FORM 8R 8 <br /> 110810 <br />