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Client N AS _TKRlt.-RTIbA <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address P►bI6bXAo5 Kl?bN& AI j5�- <br /> Water Labs (please print) Phone No. �`jl `j ��y 5(0 <br /> Proj. Mgr./Contact PAOt,. ZM% <br /> 1060 iz <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> \ <br /> Modesto,CA 95352 1430 Carpenter Lane 1 White and Yellow-To Lab with Sa plp <br /> (209)527-4050 Modesto,CA 95351 Record of Yellow-Return to Client C:- W W <br /> a•. <br /> PROJECT/SITE NAME: �, �1 `fa 1D ANALYSIS REQUESTED tt'I < to <br /> Lj <br /> PROJECTlCONTRACT/PO NO.: <br /> LU CD Cr <br /> NAME OF SAMPLE �� V REMARKS/SPECIAL INS=IONS 7 <br /> 4 W <br /> ~—LAB USE ONLY SAMPLE a m NUMBER �� Q <br /> LAB I.D. I.D. )ATE TIME O cc CON - Q <br /> V 0 TAINERS <br /> p 3 z6 I o�Z �( v� SSU <br /> 5 bOT+1 kvb ItAl 1 X Z� LU4 Z <br /> _3 ti ,s>, "u b'!� X60 So� <br /> i <br /> i <br /> RELINQUISHED BY SIGN DATEITIME RECEIVED BY SIGN DATEITIME RECEIVE FOR LABORATORY <br /> BY(SIGN): L- V-- DATE/TIME -1/1 WR <br /> 9v � <br /> RECEIVED: <br /> �I <br /> *OLD AND INTACT OTHER PRESERVATIVE OYES�KNO <br /> OOTHER: <br /> Z; 0 TURN AROUND TIME: f. <br /> z SHIPPED VIA: llzNtD X OUPS OOTHER: SHIPPING ORDER NO.: <br /> [IN-Hr 02-Day 5-Day 010-Day <br /> 4 <br />