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Client O' <br /> California SAMPLE CHAIN OF CUSTODY RECORD Address? /_M Nc,,nf MA*_eErr ;fl <br /> Water Labs (please print) Phone No��i�)�Z/ <br /> Proj. Mgr./Contact joC /Ul r-170 s oy <br /> 4 U� _. <br /> P.O. Box 4249 Ship samples to: Pink• Field Copy <br /> t: <br /> Modesto, CA 95352 1430 Carpenter Lane -,- ' ,' White and Yellow -To Laboratory with Samples <br /> (209)527.4050 Modesto, CA 95351 FEBRecord "of Yellow-Return to Client <br /> PROJECT/SIT NAME: L(`1 ';i I ANALYSIS REQUESTED <br /> U_ .0 > -65 <br /> PROJECT/CONTRACT/P0 <br /> CT1P0 O.: 1 ,� <br /> L q, U0 _O© <br /> AM OF AMPLER: 1j" REMARKSISPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE Q NUMBER <br /> OF <br /> LAB I.D. I.D. DATE TIME VCON- <br /> TAINERS <br /> �9�7 s r Y I <br /> 5c, -r/7A)e�1 ST i <br /> f{ NQUISHED BY SIGN DATEfTIME RECEIVED BY SIGN DATE/TIME RECEIVED FOR LABORATORY <br /> BY(SIGN): _ r DATErrIMEC�7 <br /> D <br /> RECEIVED: <br /> �COLD AND INTACT OTHER PRESERVATIVE ❑YES �NO <br /> ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: OFED X OUPS ❑OTHER: SHIPPING ORDER NO.: 024-Hr 02-Day 05-Day10-Day <br />