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Receiving Laboratory: Please return original form after signing for rtceint of smile.
<br />hitcA wil.a. . , - _Jc/Fik.
<br />' Phone (916) 782 2110 '
<br />FAX (916) 786-7830
<br />Send results to:
<br />Aegis Environmental
<br />801 Riverside, Suite C
<br />Roseville, CA 95678
<br />AEp.IS Environmental Consultants, Inc.
<br />Sample Identification/Field Chain of Custody Record
<br />Location Field IDit
<br />Date/Time Comments
<br />mpler(s) (signature)
<br />Field ID Received B (signature) Relinquished B (signature)
<br />4 Date/Time: Shipment Method: Sealed for shipment by: (signature)
<br />Site Address:
<br />AEGIS Project #:
<br />Shipped By: Is.v•
<br />Shipped To: A.) T L
<br />Project Manager fri, /1J.k.vv,c.
<br />Sampling
<br />Date
<br />Sample
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<br />Date/Time: Comments: e •
<br />AFE:
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<br />Shell Engineer: O f; 1.46 1(1 )1 ./,
<br />Hazardous Materials Suspected? (ye
<br />No. of Analysis
<br />Containers Re uired
<br />For Shell Projects Only
<br />WIC: `‘)
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