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' GORE-SORBER®Screening Survey Chain of Custody <br /> " For W.L.Gore&Associates use only <br /> Production Order# 14071063 <br /> ' GORE <br /> W. L. Gore & Associates, Inc., Survey Products Group <br /> ' 100 Chesapeake Boulevard• Mktoia Mmyland 21921 . Tel:(410)392-7600*F=(410)5064780 <br /> ' Instructions: Customer must complete ALL shaded cells <br /> Customer Name: URS CORP INC Site Name: DEPT OF CORRECTIONS <br /> Address: 2870 GATEWAY OARS DRIVE Site Address: TRACY CA <br /> ' SUITE 300 <br /> SACRAMENTO CA 95833 Project Manager: MARGARET HOGABOOM <br /> Phone: (916)679e"taKV0 Customer Project No.: )93 alla7, 0/001 <br /> ' FAX: Cq,tlp 10-79' 3900 Customer P.O.#:206241 US Quote#: 230643 <br /> Serial#of Modules Shipped #of Modules for Installation 50 #of Trip Blanks 3 . <br /> #598987 #599039 # # Total Modules Shipped: 53 Pieces <br /> ' # # # # Crtal Modulesceiseda: Fievas <br /> -,� t:• <br /> # # # # Totd.modwoilustalled.,' Pt es. <br /> # # # # SenaLil ofTripLues(Client j➢ezar3rs� <br /> # # # # # 59903o 14 # <br /> # # # # # # # <br /> # # J # # # <br /> Prepared By: �..�i # # #- <br /> Verified By: Ja # # # <br /> ' 1 ostsll taop Fe yne�dp <br /> By., Installation Method(s)(circle those AW ppp { <br /> Name(E*hwapriW' )i, Ak,:r Rcra +63)2 Qyvs Slide Hammer. ammer Drill u. r. u reSS <br /> GotupanpfAffiliation: U :: other: Yh�l <br /> ' InsY011ationStartDate,andTvne; -qf50Mq1ff D`f) gp J PM <br /> hutallafiohomPlete Datt and7'auus: OBJ. ✓ p ../a 3 AM <br /> Retrieval Persorrd�tl$ � '!!ordl Ivfadules 1t1 •: a�� • Preeaa <br /> Noealaie riht5i:l� bex _ Ti�tal Modules,Lest in 1d: Pieces <br /> m <br /> ' p y Total Unused Modules Ixntrued: Pieo$s <br /> Retrieval Start Date and Timex 06 lag 1 p og : Z� 'PM <br /> ' Retrieval C©mplcteDate an e: 05 1*d 8EI`� 0 9 <br /> Relinquished Date Time Received B ��a Time <br /> Affiliation: W.L.Go'e&Associ es,Inc. 711 ;Q ffiliation: 7/3170` iyoU <br /> ' Relinquished By gate Time Received By: Eii Date Time <br /> By- <br /> Affiliation,on: /4th t6g5 Affiliation: <br /> Relinquished By Date -Time Received B Date Time <br /> ' Affiliation Affiliation: W.L.Gore& ssociates,htc. <br /> ' GORE-SORBER0Screening Suovey is a registered service mark ofWL. Gare&Associates,Im FORM 8R8 <br /> 110810 <br />