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Phone(91t,, r82 2110 3.3 Send results to_ <br /> i;AX (216)786-78.30 AEGIS Environmental Consultants, Inc. AegisEnvimnmental" <br /> .' Sample Identification/Field Chain of Custody Record 1050 Melody Lane,suite 160 <br /> Roseville,CA 95678 <br /> 2! ; ` For Shell Projects Only <br /> Site Address: WIC: <br /> AEGIS Project#: sQ 0 — AFE:— <br /> Shipped By: _- _ CT/DL: <br /> Shipped To: Shell Engineer: <br /> Project Manager 1. r?�'__ [�>n�<3CiZ Hazardous Materials Suspected?(yes/no) <br /> Sampling Sample No.of Analysis <br /> Point Location Field 1110 Date '1' a Containers Re uired <br /> M tj -Z <br /> M U - 3 <br /> `1 &A 1i <br /> Mw - <br /> L)- <br /> � <br /> Oe <br /> Sampler(s)(signature) rn <br /> WWIZ <br /> Field ID Relinquished By(signature) Received B (signature) Dale/Time C !§as <br /> G� s 4 Lo : <br /> zns <br /> �7 D ca <br /> C in <br /> Sealed for shipment by:(signature) DalcR'imc: �u - Shipment Method: <br /> Received for Lab by:(signature) 4 Date rime: V z./44 oLr,_ Comments: <br /> Receiving Laboratory: ['lease return original form after signing for receipt of samples. <br /> WhitcJOriginal Ycllow/Lah Copy Pir k&dc Copy <br />