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DW ® ® ® ® A W AWJ U iilJ l lll� t� t I� �■■ tlfiiiiiil� t r l <br /> i CHAIN OF CUSTODY RECORD <br /> Advanced <br /> Date q^ 1 1"q �b Page I of <br /> GeoEnviron mental, Inc. <br /> 4005 North Wilson Way Stockton,Caldomia-95205-(209)467-1006-Fax(209)467-1118 G <br /> Project Manager Tests Required <br /> Client t .c � Cece�t;eti; `I (, `etralq 'bb�a% <br /> I <br /> Phone Number fly <br /> 1.04 - ti U. 1006 <br />' Samplers (Signature) Invoice <br /> �/ AGE <br /> Project Name G Iq #1r0 y,�.J J tr to C[� 5104/1 "t om '�"'"�"'1 ¢ Client <br /> Sample Location Sample Type Solid <br /> No of ,�' <br /> Number Description Date Time Water Air Conts `Y�' Notes _ <br /> Comp Grabs <br /> t pry <br /> u5T -)- q -it-n q-11-Q5 13:q9 <br /> i <br /> u5T �3 4 i1 ,Q� 13:x$ S ` <br /> F <br /> it <br /> i r 8 13;51 , <br /> e <br /> K <br /> I <br /> F <br /> 4 <br /> Date/Time <br /> e inqurs a y ( Ignat re) a ve y igna a <br /> � ,• ora <br /> Dsfe(Time <br /> l Relinquished by ( Ignalure) Rece ed by (Signa re) <br /> c <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis (Signature) DaterTime <br /> Dispatched by (Signature) Date/Time Received for Laboratory by DalelTime <br /> Laboratory Name <br /> Method of Shipment 14 L C4 h�f <br /> C alroixeq�g� lee& Qrr ` ��77 TT I ' U ! <br /> Special Instructions r�y� V' �OiU MEAL r� l I hereby authorize <br /> (�the <br /> �performance of the strove indicated wor <br /> i , , . � n <br />