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California Water Labs <br /> P.O. sox 4249 Client /1 1 LL E{Q ScJ/�P2 y <br /> 1430 CARPENTER LANE Address y/S5• SAz/2Ac�'"'`t^'TU ST CLopi l <br /> MODESTO,CA 95352 Phone No. -3-34 – -37 <br /> a r <br /> PHONE(209)527-4050 <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: 1;'I UI.L E A 5 V I�PLV <br /> 1' <br /> SAMPLERS (signat e) ,}/ r Number QCQc L6b <br /> of �L ' REMARKS <br /> Station Con- / //�� • <br /> Number Date Time o b Station Location tainers <br /> il)P SAMPLe C1) jKiPO4u � — 3 3 <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <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 /> Reli ui ed by gnature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Cony or Agency: (_Q/,pp (signature) Cw� <br /> w L 1 <br />