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Client <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address <br /> Water Labs (please print) Phone No. <br /> t1' Modesto, <br /> O079 Proj. Mgr.IContact <br /> P.O. Box 4249 Ship samples to: Pink- Field Copy <br /> CA 95352 1430 Carpenter Lane white and Yellow-To Laboratory with Samples <br /> (209) 5274050 Modesto, CA 95351 Record of Yellow- Return to Client <br /> PROJECT/SITE NAME: ANALYSIS REQUESTED <br /> PROJECTICONTRACT/PO NO.: <br /> NAME OF SAMPLER: REMARKS/SPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE a m NUMBER <br /> 2 <br /> LAB I.D. I.D. DATE TIME O GON- <br /> O m TAINERS <br /> N <br /> RELINQUISHED BY (SIGN) DATE/TIME RECEIVED BY (SIGN) DATE/TIME RECEIVED FOR LABORATORY <br /> BY(SIGN): DATEITIME <br /> RECEIVED: <br /> CCOLD AND INTACT OTHER PRESERVATIVE ]YES ENO <br /> ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X ]UPS ❑OTHER: SHIPPING ORDER NO.: E24 Hr E2-Day E5-Day 1110-Day <br />