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Client <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address �� STT �A <br /> f" Modesto, <br /> Water Labs (please print) Phone No. 2� h0 X3331Lt2 ,� Proj. Mgr.IContaclP.O. Box 4249 Ship samples to: Pink- Field COpy <br /> CA 95352 1430 Carpenter Lane White and Yellow-To Laboratory with Samples <br /> (209) 5274050 Modesto, CA 95351 Record of Yellow Return to Client <br /> PROJECTISITE NAME:4+70C6ray flO-1f¢C6 G17AO9 GLl,P ANALYSIS REQUESTED <br /> 51 134 VP <br /> PROJECT/CONTRACT/PO NO.: <br /> I, ME OF SAMPLER: [V \�W wJQQ REMARKS/SPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE2 mQ NUOOF ER/ y. ��. <br /> LAB I.D. I.D. DATE TIME U T CON- <br /> a2 3�- 3 19 3.OD ✓ Z �/ ✓ T/YK 'r2 u/E5T 0 <br /> —a a!'/ 3'as ✓ 2 ✓ ✓ ✓ ✓ TAirr � / uiEs� r� /Oi <br /> _ 9 �Z 3:2S ✓ Z ✓ ✓ *Vv <br /> 7;gN "�V/ 7HNt'�Z✓ ✓ ✓ TqN�#3 Grrefr ;� 9� <br /> ✓ 2 ✓ ✓ ✓ ✓ ✓ T NKA 3 QST w� /O' <br /> RELINQUISHED BY(SIGN) DATE/TIME RECEIVED BY SIGN DATE(TIME CEIV D FOR LABORATORY <br /> G 1� BY(SIGN) � DATE/TIME -2 7_ <br /> 90 <br /> RECEIVED: <br /> "9COLD AND INTACT OTHER PRESERVATIVE ❑YES\XNO <br /> COTHER: <br /> TURN AROUND TIME: �/ <br /> SHIPPED VIA: ❑FED X ❑UPS ❑OTHER: SHIPPING ORDER NO.: [124-HrC2-Day X5-Day E10-Day <br />