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Client --1116P57Prrr /U�e i P <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address S'7`oe—4,- <br /> Water Labs (please print) Phone No. `�`�g -G /"7 `/ <br /> Q O 8' Proj. Mgr./Contact <br /> P.O. Box 4249 Ship samples to: Pink- Field Copy <br /> tIl� Modesto, <br /> CA, 95352 1430 Carpenter Lane / White and Yellow-To Laboratory with Samples <br /> (2091527.4050 Modesto, CA 95351 Record_of_ Yellow-Return to Client <br /> PROJECT/SITE NAME: ANALYSIS REQUESTED <br /> PROJECTICONTRACT/PO NO.: <br /> NAME OF SAMPLER: n �7 REMARKSISPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE d m NUMBER <br /> ¢ OF <br /> LAB I.D. I.D. DATE TIME O ¢ CON <br /> - <br /> O O TAINERS <br /> 8a 97 ���? ,� �y a- <br /> $ )/Z d 150 �` 71 0. <br /> RELINOUIS BY SIGN DATEtTHAE RECEI ED BY SIGN DATElrIME RECEIV D FOR LABORATORY <br /> 11:k) BY IIE IYAD `13 <br /> \R/ECEIVED: <br /> WyCOLD AND INTACT OTHER PRESERVATIVE ❑YES�NO <br /> DOTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X CUPS ❑OTHER: SHIPPING ORDER NO.: 024-Hr 02-Day D5-Day r"D-Day - <br />