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California Water Labs ��,�� <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANEFILE C 0 P Y AddressPhoneNo. )/ w• NATz'N ��D. -i7oyt STo) ear <br /> MODESTO,CA 95352 6-a q —56 5- 3 <br /> PHONE(209)527-4050 - SCa <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) G <br /> PROJECT NAME: S'C M Z— BOO l !�C A e'er V \ 1 �� �s S , <br /> a <br /> SAMPLERS (signat e) ' ¢ Number IV �D D <br /> Of ` <br /> \ REMARKS <br /> Station a a \` L a\�sr <br /> Number Date Time u Station Location tamers Q t a° <br /> � <br /> 13-tie n.v3 3° •13 <br /> Jsa/nriL ) M.P PL.-: <br /> p <br /> 'RNK � 11 S caraP e ' C ) Mi00Le y I <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agenc.}: Company or Agency: <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received by (signature): <br /> Company or Agency: Company or Agency:- Company or Agency: Company or Agency: <br /> _ Rel qu hied b signature e ( Time Received for Laboratory by: Date /�Tim)e Remarks/Shipping Information <br /> Co any or Agency: <br /> CwL - ��, tl � 11 L •�vC� 1 , v <br />