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California SAMPLE CHAIN OF CUSTODY RECORD AddreClient - <br /> Water Labs Phone SNo. >0 t 5 m T� C'{i <br /> (please print) <br /> Proj. Mgr.IContact Al I <br /> � I P.O. Box 4249 Ship samples to: 1306 <br /> Modesto, CA 95352 1430 Carpenter Lane Pink- Field Copy <br /> (209) 527-4050 Modesto, CA 95351 Record of White and Yellow-To Laboratory with Samples <br /> Yellow-Return to Client <br /> PROJECT/SITE NAME: —1" 5 w 1 SE(nN p ST t ANALYSIS REQUESTED <br /> tz!t <br /> to}ry\ 01CC- lN� bC 76th S LI <br /> PROJECT/CONTRACT/PO NO.: ! q <br /> NAME OF SAMPLER: <br /> REMARKS/SPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE a m NUMBER /��� <br /> LAB LD. LD. DATE TIME O CON- �' r <br /> O O TAINERS <br /> TAPK 1 — ISTD GAL., o)ES-tc- L- <br /> E N � ThIJ96-AL, (LZG, 6A5 <br /> A� T �d I <br /> A Kb <br /> FsT 1. <br /> RELINQUISHED BY SIGN) DATE/TIME RECEIVED BY (SIGN)' DATE/TIME RECEIVED FOR LABORATORY <br /> / 1 BY(SIGN): 1 L}I DATE/TIME L ( U <br /> FREIVEDOLDAND INTACT OTHER PRESERVATIVE ❑YES ❑NO <br /> THER: <br /> (.y- TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X ❑UPS OTHER: �'� SHIPPING ORDER NO.: 024-Hr 02-Day - ay C10-Day <br />