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1r � � � � �� tttl■tttttti � � .�. <br /> CHAIN OF CUSTODY RECORD <br /> � Advanced Date 1 f2s='�� Page � of <br /> --- %'- GeoEnvironmental, Inc. <br /> 4005 North Wilson Way-Stockton,California 95205-(209)467-1006-Fax(209)467-1118 <br /> Client Project Manager Tests Required <br /> Phone Number <br /> Samplers (Signature) �� Invoice <br /> AGE jg <br /> Project Name � .� ! Client ❑ <br /> Sample Location Date Time Solid Water Sample Type No of Notes <br /> Number Description Comp Grab Air Conts <br /> AU-4��) `> r' tom ' 114C�1-• 6R 1 <br /> o I.06 f <br /> -1 T ------- <br /> Relinquished y (Signature) Received by ignature taalefrrme <br /> d by Signature} Received by (Signature) Date/Time <br /> Relinquished by (Signature) Received by Mobile Laboratory for field analysis (Signature) Datejtme <br /> Dispatched by (Signature) Date/Time Re etv or Laborahry by Date/Time <br /> Method of Shipment 71 <br /> Labor tory Name <br /> C° cler I hereby authorize the Performa ce f the above Indicated work <br /> Special instructions <br /> � ry <br /> r <br />