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r <br /> Phone(916)( L 111) ri <br /> AEGIS Environme4iol Consultants Inc. �_/r send results r i h <br /> FAX ;91G)78b-783(} � Aegis Environmenl:il ,• <br /> Sample Identification/Field Chain or Custody Record 801 Riverside,Suite C <br /> Roseville,CA 95678 <br /> "i:! <br /> -� b 'hell Projects Only <br /> Site Address: s��, _ � WIC: <br /> AEGIS Project#: � �-�l _ <br /> Shipped By: <br /> L i.� -- APE: <br /> Shipped To: Iti l Sh 11 <br /> l L 9� — Shell E neer: <br /> Project Manager v% Jae <br /> Materials Suspected? (yes,/n <br /> Sampling Sample No.of Analysis <br /> Point Location Field IM DateI' a Containers R aired <br /> � wca <br /> Sampler(s)(signature) <br /> Field 1D Relin uis ed By(signature) Received By(signature) Dale/Time Comments <br /> ~� 7`0 , i� NCS <br /> Sealed for shipment by: (signat 4rek Q ! Datefrirn q2- q Ai-,- Shipment Method:p t e lco if <br /> Received for Lab (signature)by: nature — <br /> g } �L, D:rlc/]`imc: 2/,�mlcrz- Q. 'bo Cominentsr]`r�Jrii� <br /> Receiving Laboratory: Please return original form after signing for receipt ol'sarnples. <br /> WhiuJQriginal YCHOWAA0copy Pink/hIcCopy <br />