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California Water Labs <br /> P.0. BOX 4249 Client LY)bLLM SUPPI y <br /> 1430 CARPENTER LANE Address 411S S. SRZRA.�+EN rU ST Ci.oD� 1 <br /> MODESTO,CA 95352 <br /> PHONE(209)527-4050 Phone No. 334 - 37Y,I , <br /> Contact Person V/ RG-/ N/ A <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: I 4 L t A <br /> 1' 4M y 1 J Q <br /> SAMPLERS (signal e) r c O <br /> ¢ P <br /> Number e� <br /> 011/0 <br /> of �L REMARKS <br /> Station L <br /> Number Date Time Em Station Location Con- ,v"\ <br /> -& 7y u c`� tainers \I <br /> `; SRf RRM E/•"r0 T <br /> a— 33I <br /> Relinquished by(signature): Date / Time Receiviceh4; signature): Relinquished by(signature): Date / Time Received by (signature): <br /> Company or Agency: CompanyorAgency: 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 /> Rel iijui , ed bye gnature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> 1 (signature) CWL <br /> Comny or Agency: /(.e �Q <br />