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a� CSHELL <br /> �. aaaaaiaws�aOCL COMPANY CHAIN of cusTODv� RECORD stele I <br /> RETAIL ENVIRONMENTAL ENGINEERING - WEST Serial No rr 4 Page I of <br /> Site Address -14-15 c�t�hi r1G� ve_n vr--, Analyses Required u LAB: _Q� � T P�� �j� <br /> s�k fc�n — <br /> WI(Ili �- -� 4}� CHECKONE(1)BOX ONLY CT/DT TU RN AROI I N D TI M F <br /> Shell Engineer Phan No 2 u �'T Quarterly Monitoring 5461 24 hour <br /> S1D d <br /> y� } Fax M—] <br /> c Site Pnvestigation 5441 48 haus <br /> Consultant Name A Address ^ 'L Sal for disposal ( � 5442 <br /> 43,3U Sy��-i4��� 9 3`f-- O +� Water far disposal [ 5443IS days [ IN�xmalF <br /> O 1 <br /> Other <br /> Consultant Contact. Phone No q 16 !! Air Sample-Sys OAM [ 5452 — <br /> q z B -33c<:) oo V NOTE Notify Pah as <br /> Fax#- 2 A N Water <br /> - Sample Sys O&M U 5453 soon as possible of <br /> Comments G IDf-Q q G N [ U 24/4$hrs TAT <br /> Pl <br /> ri <br /> Sampled By A ur SAMPLE <br /> MATERIAL <br /> Printed Name V fPLv✓ 6- �',+ DESCRIPTION COMMEINTS <br /> Sample ID--- — Date Soil Water Air No of~ pq H Q <br /> H <br /> z '1JJ X- Ij I <br /> AA <br /> -- <br /> y <br /> I-A <br /> �v <br /> ,,. <br /> Rchngius d (signature) - -� IPI)nlc <br /> 4 name/ Date 9 Receiv tgnalttre) -- - printed name Datc z�91 <br /> } cv �_ Time 0 F ., i - c: Time •�_ <br /> Rrlim shed B (signature Printed name Dale a ecety s tore) KOM name Datc_y Z 7 <br /> / 6 Time as d-- J. 3 .J Time /,? C/p <br /> clinyu ed By (si e) Prins d�naime Date 2Z i (signature) Printed name Uaie <br /> V• l�G w Time ,5�� r e+ ,�f 1�/ �7c.. !, Time Obi o <br /> THE LABORATORY MUST PROVIDE A COPY OF THIS CIIA F CUSTODY WITII INVOU E AND RES01 TS <br /> .i+� k,vi,uni I]atc llyl�Nl <br />