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{ Advanced CHAT F USTODY RECORD <br /> ---- Date 5page � of <br /> GeoEnvrronmental, Inc. ��`��7� <br /> 837 Shaw Road Stockton, California- 95215 - (209)467-1006 Fax (209) 487-11!8 <br /> Client � protect Man r Tests Required <br /> [C <br /> one Nqmbel <br /> 3 <br /> Sars (St ture) Invoice <br /> Project Name AGE <br /> Client <br /> Sample <br /> Sample Location Date <br /> ate Tree Solid No of <br /> Number Description Water <br /> Grab Air Conts Notes <br /> ..sal <br /> 00:)COND <br /> ?AD SPAQ Rh"TItV <br /> W La <br /> 13'T <br /> elinqurs y (S n ure} ecetve y (Signature) <br /> ate/Tim <br /> Relinquishedby (Sig ature) Received b Sr nature <br /> Y ( a ) Date rima <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis (Signature) DateJTirne <br /> i <br /> Dispatched by (Signature) Date/Time IRe i or Laboratory b / PatefTirne <br /> Method of Shipment LaboratorQa e <br /> Special <br /> Inst�ruc�tion�sI hereby auth rrzthe <br /> p r rmance <br /> WO the above indicated work <br />