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JI_IN-05-2000 16:20 OCWEN FEDERAL 1 561 682 8161 P. 10:1 <br /> a:71 r-mufi; IW1NiNta1 "44 ), INC. 559-268-7125 TI- '982972119 P-009/016 <br /> CORE-SORBER®Screening Survey Chain of Custody <br /> Fur W.L. Gorc&A.SocizWx use only <br /> Production Order# �D4770d5 <br /> W_ L. Gore & Associates, Inc., Environmental Products Group <br /> 100 C svp'akr Br2k2ard• ElUon, M land 21911 • Tel (d IO)392-7600 •Fax(410)506-4780 <br /> InSITuCtiOnS: Customer must complete ALL shaded cells <br /> Customer Name: TWINING LABS, INC. Site Name:—.82,,7 4,r <br /> Address: 2527 FRESNO STREET Site Address: 3Yt;_W <br /> PO BOX 1472 <br /> FRESNO, CA 93721 Project Manage: 'k �I <br /> Phone: 559-268-702I Customer Project No. <br /> FAX 559,-269-7126Customer <br /> P.O.#: Quote 2D5428 <br /> Serial#of Modules Shipped #of Modules for Iris ra 0adon I3 #of Trip Blanks I <br /> tx 3275b5 #327574 #I - fr Total Modules Shipped: 14 Pieces <br /> #327578 #327581 # Total Modules Rr_crived: lyPieoes <br /> # # # - # Total Modules Installed' 3 Pieces <br /> # # # - # Serial#of Trip Blanks(Clieru Decides) # <br /> # * # - # # # # <br /> # # # _ # # # # <br /> # # # _ # # # # <br /> # # - # # # # <br /> # # # - # # # # <br /> CORE ANALYTICAL OP'ITON: # # # <br /> [A 10 J # # # <br /> b9all>ation Performed By: IWWWUon Method(s)(circle lhuse that apply): <br /> Nam=(please print): f�ye� fide Hamm r Augcr <br /> Coman <br /> py/Affiliation: Other: <br /> Installation Stare Date and Time: C�q /Zy Oct :to PM <br /> Installation Complete Dare and Tttne: 04 /Z / a 14 :1.5 <br /> AM <br /> Retrieval Performed By: Total Modules Retrieved pig <br /> Name(please print). t Total Modulen Lost in Feld _ Nieces <br /> Company/Affiliation.l Total Unused Modules Retumed., l -TLS pieces <br /> Retrieval Start Data and Time. 05 1 O / 0-0 p :oaf PM <br /> Rcuicyal Complete Date and Time: / ge, / FM <br /> Relinquished Byt Time Received By. Dwz Tune <br /> Affiliation: WL.Gore / ssociat ,Inc_ Q� Affiliation; �t• 4/ l0 <br /> Relinquished By i imc Rccrived By lr a Time <br /> fliatioa: 'fu�.i ars{r� O'� la,r► Affiliation: ut, ' n� <br /> ellnquished$y _ Time Received By: ' Detc T{¢to <br /> Atfilietio ;rt <br /> } � � A"` A�liauion: 11V,L_G dt Assoclatcs, Inc. '�O� I l -� <br /> GORE-SOR8ER ®.Screening Surrry i$a registered service mtarh of WL Core A Amocietes. Iftc. FORM 8K5 <br /> 311aw <br />