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IN <br /> California Water Labs <br /> P.O.BOX 4249 <br /> Client �_(�N l�S S�PT I C <br /> 0430 CARPENTER LANE Address. O N. Nw'Y `I F��°N1ftGr <br /> MODESTO,CA 95352 <br /> PHONE(209)5274050 Phone No. g- S 105 `— <br /> Contact Person pi N Cl� <br /> CHAIN OF CUSTODY RECORD (please print) Z <br /> PROJECT NAME: WC57ERN Mt-TE RW 5- sEpTf�-- <br /> Cyt� d <br /> SAMPLERS (signature) zv� ° <br /> Number Q� b b\ p C�C� Z ` <br /> of REMARKS l� <br /> 5tatlon Con- ` <br /> Number Date Time o Station Location tainers <br /> u cS <br /> a 5-4oq N. pwq 94 flto+,r,4CF <br /> +".E-sr matin �- c I <br /> nn PI a. <br /> TANK �Z �;�a �suo Nw . <br /> wE5 U <br /> h rn P! j -A <br /> Rein ished y(signature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Receivee by (signature): <br /> 'Z'1 i� - <br /> Company or Agency: / s Company or Agency: Company or Agency: Company or Agency: <br /> C— <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 /> Relinquished by(signat'ure): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Company or Agency: ( i at12J <br /> ur } ` <br /> L <br />