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California Water Labs sc�it� <br /> P.O. BOX 4249 Client <br /> 1430 CARPENTER LANE Address 3/ 6L' Nq 7 �D <br /> MODESTO,CA 95352 Phone No. 5)y - `1 5 3 <br /> PHONE(209)527-4050 R <br /> Contact Person <br /> /1 CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: 5'!! YMr19M SL y <br /> ^� D <br /> SAMPLERS (signature) NumberQ�Qi �/ REMARKS <br /> tC Lf( �Cy of <br /> Station11 K • <br /> Number Date Time ' Station Location tainers <br /> 0 1 r <br /> / b /y /� jp aOs 57acKYON ST.�MANIEz ` � � � _ � r <br /> cE l 10D<C J <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 /> Re�' shed ignature): Date / Time Received for Laboratory by: Date <br /> 77/�Time Remarks/Shipping Information <br /> C any or Agency: <br /> 1. C W L- Zignat re C <br />