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California Water Labs <br /> P.O. BOX 4246 Client m D <br /> 1430 CARPENTER LANE `\ INAddress 43) GJ•�t-�I7 , eH- �� <br /> MODESTO,CA 95352 \\\+ Phone No. <br /> PHONE(209)527-4050 C <br /> Contact Person <br /> ? CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> /� 435 CE1�ITRA-L L!-�I�' <br /> 7-/ TA _ yy�O V �pNO \ \(✓Q <br /> SAMPLERS (si <br /> of K <br /> Number QC?Qz°'� /. REMARKS <br /> Station <br /> Number Date Time o b Station Location tainers Ci` <br /> U U' <br /> g2SOErJT12AI Avg <br /> T <br /> R1' ui,shed by(signature): Date / Time Rece' d by (signatur Relinquished by(signature): Date / Time Received by (signature): <br /> /E 93 8 is <br /> Cgmpan9 or•Agency: . h�� Cam ny a Company or Agency: Company or Agency: <br /> a <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 /> ReyrF�uis by si n ture): Date / Time Rece ved for Laboratory by: Dae / Time Remarks/Shipping Information <br /> Com— (si nat e)- <br /> Co an cy: # �� � J <br /> �� / <br />