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California Water Labs <br /> P.O. BOX 4249 Client <br /> 1430 CARPENTER LANE Address/ 323 <br /> MODESTO,CA 95352 <br /> PHONE(209)5274050 Phone No. <br /> Contact Person , A i�ox oC <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> NAME: <br /> G <br /> SAMPI,.E�(sl9nature) � �b� a <br /> YUi(signap /p�l/� Number �1 <br /> I of Q ' REMARKS <br /> Station p a Con- <br /> Number Date Time Station Location tainers V <br /> u c� <br /> C <br /> ! 3— � T•�hu,e a" - � � - S`�2`15 <br /> ,y <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 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 /> Rrz/7.ez- <br /> shed by(si atur Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> L <br /> d'f' ent <br /> 2% (s au ��� �3 �,�-.2t�c ��TYt- Ccntr' <br />