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Qeelogical Technics Inc. <br />1101 7th Street <br />Modesto, CA 95354 <br />(209) 522-4119 / fax (209) 522-4227 <br />geologicaltechnics@sbcglobal.net <br /> <br />; <br />Project # <br />gito , 2. <br />Client/Project Name <br />_ i,,,,. 0 to gs Afritic.:11 No. of Containers] ••5.' '11 '''' . <br />\--- Laboratory Name & Address < <br />i <br />ampled by; , (signature). A <br />, , - ...., <br />Da te Sample I.D. .._. <br />LI& ilk 7:POI'Srf - - 1.2". „---- 1 - --;--- <br />, • r f <br />PA, L- .. - R CI) - . <br /><,. . <br />...,,,r • - ,;,-"t•Vi_e5- ‘....„ 3 — . I. <br />\ <br />\ - <br />\ <br />, . <br />, . <br />- <br />\ \ _ - -, - , , __....... <br />Rqin lui4heill by: (signature) <br />0 ( ti -ail <br />Date/Time <br />' Val g'..: '-.7-- <br />Fceived_by:, (si niature), <br />/tit . • A, <br />PLEASE RETURN SAMPLE C9NTAINER . <br /> <br />&,_Y-4. k;:._.),-7-„.. <br />CC: <br />- ' <br /> <br />— ..._ ,._. -... „.:.... <br />_ <br />Remarks: <br />Relinquished by: (signature) Daft /Time Recleived by: (signature) <br />Relinquished by: (signature) Date/Time <br />I <br />Received by: (signature) <br />\Zs- <br />t