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California Water Labs <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address <br /> MODESTO,CA 95352 2 S3 <br /> PHONE(209)527-4050 Phone No. <br /> Contact Person <br /> "- CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> jDate <br /> e) o <br /> Number a�� <br /> of REMARKS <br /> oaCon- \e Station. Location tafners <br /> uv 63 E.S1-' <br /> 2� 130 3� <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 /> Comps a-Agency: Company or Agency: . Company or Agency: Company or Agency: <br /> R,elin ature): Dat ��Tim? Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Co p n , (signature) <br /> r i <br />