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client — <br /> Mj� Cgdornia SAMPLE CHAIN OF CUSTODY RECORD Address y3f W- //4a /7&4. <br /> ater Labs (please print) Phone No. (ZoT) Sty - 16 S3 . • <br /> 0057 Pro]. My./Contact <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> Modesto, CA 95352 1430 Carpenter Lane White and Yellow-To Laboratory with Samples <br /> (209) 527.4050 Modesto, CA 95351 Record _of Yellow-Returmto Client <br /> PROJECT/SITE NAME: ANALYSIS REQUESTED <br /> 'ir4cz, Pre <br /> PROJECT CONTRACTTIPO NO.: 1b) <br /> NAME—OF�SAMPLER: REMARKS/SPECIAL INSTRUCTIONS <br /> V. <br /> LAB USE ONLY SAMPLE a m NUMBER / <br /> f < OF (� <br /> LAB I.D. I.D. DATE TIME O ¢ CON* <br /> O m TAINERS <br /> X 3 52 ro-t r X X x I I Qe,t-v <br /> 53 J/ o X 1 v u S / <br /> sy 0 X 1 v k sari <br /> RELM S BY SIG DATEITIME RECEIVED BY SIGN DATEfTIME EC IVED FOR LABORATORY <br /> BY(SIGNI: ' 1! . -' DATEITIME / r <br /> RECEIVED: <br /> COLD AND INTACT OTHER PRESERVATIVE CYES\N,�NO <br /> COTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: CFED X CUPS COTHER: SHIPPING ORDER NO.: 024-Hr C2-Day C5-Day --�,10 Day <br />