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California Water Labs <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address '/V rc,Z4 0.<Atbl�rSrad <br /> MODESTO,CA 95352 Phone N0. 5-;L4/-9(, ,5 !5 <br /> PHONE(209)527-4050 <br /> Contact Person Sca 77 <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> 150/X` GV�STElZI�I Sra�"t cjy��D �O� oft) \� Q A <br /> SAMPLERS (si nat ) Number Q'Qz <br /> All Of ,�0 v�JyD 'Y REMARKS <br /> hi7 <br /> Station <br /> m <br /> Number Date Time Station Location tamers `/ e �(!� <br /> TAN [ 9/ 30 0 71T11 .1 <br /> M <br /> ` l 5o rE 0 1� C`/ c/I. P�Q <br /> �N{tC� 3I?f 330 IE �l�) ihMv LE X ' <br /> N 3� 44 <br /> 1AN(�(3) 1�B qN MPLE ('5-,A If Wg7E <br /> rAA V-a 13 eRN 1 <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 /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Ret shed yd(sig9nature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> � A, " 8 G *j (signature) <br /> Co any or Agency: y/ I• y <br />