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California Water Labs <br /> P. Client Sr/hto�wESTE�N S7aNE <br /> 1430 CARPENTER <br /> LANE <br /> 4 cn MODESTO,CA 95352 Address 43/ 4J. l-1RttH lQr7, <br /> - 2 U PHONE(209)527-4050 Phone No. 5-.2 9G 5-3 <br /> sContact Person 5'c OT <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: SEMcp/W &57EP0 5'7VN4C- <br /> U <br /> y�a, ` <br /> D A <br /> SAMPLERS (signature) <br /> Number Q°gip (f•� n.�� �c <br /> • Station of �p\� ��'$V�� REMARKS <br /> Number Date Time E A Station Location Con- L ` <br /> U j <br /> -- � tainers �- <br /> IISMRDiSau yrocleiau V <br /> SAMPLE D LE �( y X <br /> lA. Sri 014L <br /> • <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date <br /> / Time Received by (signature): <br /> Company or Agency: Company or Agency:9 Y: Company or Agency: Company or Agency: <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received b <br /> y (signature): <br /> Company or Agency: <br /> Company or Agency: Company or Agency: <br /> Company or Agency: <br /> Relin is d by(Aignature): Date / Time Received for Laboratoryb Date <br /> �. Comp y or Agency• jy �Py signature) y ,ice Remarks/Shipping Information <br /> C-_ we . �Y I?4-71 7,f <br /> U/ <br />