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s � � <br /> -pa lifornia Water Labs <br /> P.O_SOX 4249 Client <br /> 1430 CARPENTER LANE Address Z���r�r� <br /> MODESTO.CA 95352 <br /> PHONE(209)527-4050 - Phone No. 522-965'3 <br /> Contact Person 25:67"r <br /> CHIT OF CUSTODY RECORD � (please print) <br /> PROJECT NAME: <br /> SAMPLERS (si nat e) Number Tc�p^a� Lf <br /> Zi1rti _""U,_ ' o f �� '� T p REQS <br /> Station a a r hid <br /> Number Daze Time Station Location Con- <br /> tainers <br /> (yq►`� �a �� <br /> TAV D10 G V W. TOTA zt <br /> a _14,nple ) stn wit <br /> 'MM4 3I�i 33 !E KI) <br /> t <br /> z��S MFLe ) 3 5"1iMFt6 l C WA7 E- <br /> AhVL-L (3 LAA./ i <br /> Relinquished by(signature): Date / Time Received by (signature): Relinqulshed 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 Rece{ved by (signature)- <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> yany <br /> hed {si'gnature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> � r'3 (signature) <br /> Caror Agency: y )L4 <br />