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f -k <br /> ®I6ffornia Client <br /> SAMPLE CHAIN OF.,,'JSTODY RECORD �> • <br /> Address /.-�. -- . <br /> i \ W(fle'r Labs (please print) <br /> Phone No. <br /> i 0223 Pr0j. My./Contact <br /> P.O.Box 4249 Ship samples to; hl <br /> Modesto,CA 95352 1430 Carpenter Lane Pink-Field Copy <br /> (209)527.4050 Modesto,CA 95351 Record of White and Yellow-To Latrorato,y with Samples <br /> Yellow-Return to Ctlent <br /> ! PROJECT/SITE NAME; <br /> ANALYSIS REQUESTED �� S <br /> PROJECTICONTRACTIPO NO.; <br /> 0 <br /> NAME OF SAMPLER: �XN <br /> P.EMARKSISPECIAL INSTRUCTIONS ` <br /> LAB USE ONLY SAMPLE a: m NUMBER �� P' <br /> LAB I.D. 1.13, DATE TIME O CON• <br /> Cl TAINERS <br /> s. <br /> O <br /> J3,1 -l t/,3 <br /> r k <br /> 13 /a;✓o ✓ t _ <br /> fv, <br /> RELINQUISHED BY SIGN) bATEITIME RE IVSD BY SIGN <br /> DATEITIME PICElUED FOR LABOPATORY <br /> />yM b'_!�11� E1TIM_• <br /> "T-�-• /_ �Yr BY tSIGN �'t-� DAT F .?, <br /> — RECEIVED: <br /> COLD AND INTACTs' <br /> 07HER PRESERVATIVE '---YES NO <br /> IX <br /> COTHER:._ —_„- _ N <br /> C TURN AROUND TIME; <br /> SHIPPED VIA: CFED X CUPS COTHER: SHIPPING ORDER NO.: 02-Day \/5-Da <br /> C 24 li r Y ti 10-Day ” <br /> r-. <br /> ,6.3i1 <br />