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California Water Labs SEnICo <br /> P.O.Box 4249 " Client <br /> 1430 CARPENTER LANE 'Address y3/ f/i97L�// -o7ooE.S,p <br /> MODESTO,CA 95351 <br /> PHONE(209)527-4050 Phone No. <br /> Contact Person d� <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: Aft —74014S <br /> `"_• _' <br /> rn <br /> 3/,1 o-9 elAAN s�crc'izi <br /> �. <br /> SAMPLERS (signal ) c� a Q . <br /> Ov Number <br /> of REMARKS <br /> Station <br /> Number Date Time Station Location tainers <br /> t130 3I;r 51-/wOf-14 )'060 . uxitm wo <br /> S-rOcICroAJ, <br /> * W� <br /> 4-14es 7 <br /> Relinquished by(signature): Date / Time Received by (signatur}): Relinquished by(signature): Date / Time Received by (signature): <br /> ---------------- <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: si nature): <br /> Company or Agency: ency. Company or Agency: Company or Agency. <br /> Re( uiiosheddybby(si nature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Co avGS nv" or•I(�enc�v:p�� � ��y"�� (signature) <br />