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Client <br /> OCalffornia SAMPLE CHAIN OF CUSTODY RECORD Address `/3f <br /> ater Labs (please print) Phone No. (ZoT) Sty y�S3 <br /> 0057 <br /> Proj. Mgr.IContact <br /> OX 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-Return to Client <br /> PROJECT/SITE NAME: ANALYSIS REQUESTED <br /> I t-4 c Pre Sir, u, 4 <br /> PROJECT CONTRACTIPO NO.: 't 7 <br /> JAME OF SAMPLER: /J REMARKS/SPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE a m UMBEROF <br /> LAB I.D. I.D. DATE TIME O ¢ CON- !\ <br /> O O TAINERS <br /> g735� lt, la: 2 X K X liW <br /> 53/ <br /> S`7 rn lC kZ lD 2 : I X X Sof "Ob fit' `7 <br /> RELjNjQUiSX BY SIG DATE[TIME RECEIVED BY SIGN DATE/TIME 4VECIVED FOR LABORATORY <br /> AGO'ZG b 4 BY(SIGN): /t l DATE/TIME/4,[ <br /> RECEIVED: <br /> COLD AND INTACT OTHER PRESERVATIVE OYES 0 <br /> • ❑OTHER: VVV <br /> TURN AROUND TIME: <br /> £#HIPPED VIA: ❑FED X OUPS ❑OTHER: _ SHIPPING ORDER NO.: 024-Hr - 02-Day 05-Day �_t0-Day <br />