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� � � � � � � � � � � I• i• �■ � ittititiis ■ww <br /> Advanced CHAIN QF CUSTODY RECORD <br /> -- "� GeoEnvironmental, Inc. _ Date �C gage ---L of <br /> 837 Shaw Road- Stockton, California-95215 - (209)467 1006 - Fax(209)467-1118 <br /> Client Protect Manager Tests Requited <br /> Pppne Number <br /> Sampler (Signa ure) Invoice <br /> Protect Nam t AGE <br /> 00 Client ❑ <br /> Sample Location Sample ype Date Time Solid No of � Notes <br /> Number Description Water Air Conts <br /> Comp Grab <br /> r iK 3 I <br /> tr�rice t•�r�` �Nr,J .� <br /> 1 I <br /> e to a tui Received by (Signature) at [Time <br /> }Zeit qutshed y (Signature) Received by (Signature) 1 Date/Time <br /> Relinqu she by (Signature) Received by Mobile Laboratory for field analysis (Signature) Date/Time <br /> Dispatched by (Signature) Date/Time Received for Laboratory D a/Time <br /> Method of Shipment Laboralp 991111me <br /> 6 <br /> Special Instructions t I hereby authorize the p ormance of the above indicated work <br />