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■�■■ �■■� �� � �� � fly li � ti! 1• � 1• � � ti ti � i• <br /> Advanced CHAIN OF CUSTOD RECORD <br /> _ Date �A7/04 Page ? 0 <br /> GeoEnvironmental, Inc. <br /> 4005 North Wilson Way Stockton,Califomia-95205-(209)467-1006 Fax(209)467-1118 <br /> Client Project Manager <br /> Tests Required <br /> Phone Number <br /> Sam ers (Signature) Invoice <br /> Project Name p4l_� AGE <br /> Client ❑ <br /> Sample Type <br /> Sample Location Date Time Water Solid N0 of � Notes <br /> Number Description Air Conts <br /> Comp Grab <br /> ®3,.- <br /> kLl 3- -® <br /> 4 <br /> KAW f3 , <br /> eroque y ignatur eceeve y ignatuFie Date/Time <br /> Relinq shed by (Signature) Received by (Signature) Date/Time <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis (Signature) Date/Time <br /> Dispatched by (Signature) Date/Time Rece a or Labor for b Date/Teme <br /> U <br /> Method of Shipment La rat Name <br /> Special Instructions V I hereby aut I <br /> riz4 the performance of the above indicated work <br />