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[-` 117-7 rT f F-77 r-7 f C' I? r.--7 r—! r""4 rp r-7 r-1 r-1 r"n <br /> j Advanced CHAIN OF CUSTODY RECORD <br /> Date 1 a V Page Z of Z <br /> GeoEnvironmental, Inc. <br /> 4005 North Wilson Way-Stockton,California-95205-(209)467.1006-Fax(209)467-1118 <br /> Client Project Manager <br /> � Tests Required <br /> H <br /> Phone Number <br /> 3-0q <br /> Samplers: (Signature) Invoice: <br /> AGE <br /> Project Name d N if ' �1 (6j�'. � ��'[�"' �� a� Client <br /> �• �.� <br /> Sample. L Location Sample Type Solid No. of Notes <br /> Number Description Date Time - Water CoAir Cants. Via' <br /> mp. Grab. <br /> l� 3 r <br /> - 3p �t= tiv X", — �t <br /> ig�naure� i �J Date/Time <br /> Relinquished y: (S , [r4-[ vuc�ci• <br /> T-. � �� . �t�r.r•ao r -_3v <br /> L4 tt <br /> Relinquished by: (Signature) Received by: (Signature) Date/Time <br /> Relinquished by: (Signature) Received by Mobile Laboratory for field analysis: (Signature) Date/Time <br /> Dispatched by: (Signature) Date/Time Received for Laboratory by: Date/Time <br /> Method of Shipment: Laboratory Name <br /> LA A ( i4-X <br /> Special Instructions: I hereby authorize the performance of the above indicated work. <br /> ��r�nn, �iJ�✓t-t��y[�-'1 <br />