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California Water Labs ) LuYo GuMs- <br /> P.O.BOX 4249 Client �1 <br /> 1430 CARPENTER LANE Address '731 (j(�CfI C�l6oD LoD� < <� ' es24� <br /> MODESTO,CA 95352 -3 <br /> PHONE(209)527-4050 Phone No. 3 <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: LLoyt) GUMS G, C+ V v <br /> Fi O <br /> lei <br /> SAMPLERS (signature) +�'-'t-'� Number Qui o� O� �n 0 r <br /> Of � � �b p41 � 7 REMARKS <br /> Station <br /> Number Date Time ? Station Location Con- <br /> tainers aj /� /� � 4U <br /> � �aU� IoM J sAMn�C��U6Asr ENO. I X P-1� 85�5 goo ca. <br /> TANK I tr SAMPLt � �EASrCND I X J <br /> TAN73 I1`4 AmPL9 EA5r eNl) I —I <br /> �Ka� � <br /> L = Tei "..l lead <br /> w <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date i Time Received by (signature): <br /> Company or Agency: (Company or Agency: Company -jr Agency: 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 hed b signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Com any or Agenc y,5 (signature) <br /> 1 <br /> /C,-} <br /> C.�c�� FY PM I�lCJWI Z� <br />