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Client �Q,<S <br /> C©ldornia SAMPLE CHAIN OF CUSTODY RECORD Address 1AA rb ►�Dj fl� <br /> Water Labs (please print) Phone No. <br /> i I Proj. Mgr./Contact _ j ( - <br /> / <br /> 1366 <br /> i P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> Modesto, CA 95352 1430 Carpenter Lane lie White and Yellow-To Laboratory with Samples <br /> (209) 527-4054 Modesto, CA 95351 Record of Yellow-Return to Client <br /> PROJECT/SITE NAME: -1113 w t SEL' 44D <,Xi ANALYSIS REQUESTED <br /> PROJECTICONTRACTIPO NO.: <br /> 'fib- 9603 <br /> ME OF SAMPLER: REMARKSISPECIAL INSTRUCTIONS <br /> I,) L <br /> LAB USE ONLY SAMPLE a m NUMBER Q �► <br /> 4 OF <br /> LAB I.D. LD. DATE TIME O cr CON- <br /> Y (5 TAINERS <br /> 10 <br /> -r b <br /> I �IK AX I <br /> )4x <br /> , <br /> k0 X I X X X- X `CaN#�Zf r � 6AI., �. �q <br /> ��7 <br /> -5 3 <br /> 4 �I1f1 <br /> J ,. i1.. <br /> i:7-et.T X1 <br /> RX NI I <br /> RELINQUISHED BY SIGN DATEITIM�E�r RECEIVED BY SIGN DATEMME RECEIVE FOR LABORATORY <br /> on z�0�­ <br /> DATEITIME <br /> 1 R EIVED: A <br /> COLD AND INTACT OTHER PRESERVATIVE ❑YES ❑NO <br /> • ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X []UPS PTHER: HIPPING ORDER NO.: 024-Hr E32-Day Day G10-Day <br />