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Client <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address • a)z7h� 1149&:5/c, <br /> Water Labs (please print) Phone <br /> t <br /> 0052 Proj. Mgr.IContacl V <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> Modesto, CA 95352 1430 Carpenter Lane / / White and Yellow-To Laboratory with Samples <br /> (209) 527-4050 Modesto, CA 95351 Record_of_ Yellow-Return to Client <br /> PROJECTISITE NAME: - ANALYSIS REQUESTED <br /> 2P7 S, .�ciFG �✓r-9 sT <br /> P50JECTICONTRACTIPO NO.: <br /> NA SAM : 'A n REMARKS/SPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE a m NUMBER .F <br /> M a OF p_ <br /> LAB I.D. I.D. DATE TIME O m CON. YYl r <br /> O c7 TAINERS <br /> 'XX <br /> pitpogWAIENTAL HEALTL <br /> p P,^v1 VSERTC a <br /> /REIj4QUISHED.BY SI DATEITIME RECEIVED BY SIGN DATE/TIME ,;RECEWED FOR LABORATORY <br /> BY(SIGN): p'L4tti DATEITIME 5-11/�5 <br /> RECEIVED: <br /> OLD AND INTACT OTHER PRESERVATIVE DYES l60 <br /> ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X ❑UPS OOTHER: SHIPPING ORDER NO.: 1724-Hr 11 2-Day 05-Day -Day <br /> 'd <br />