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CaliforniaSAMPLE Client S <br /> California E CHAIN OF CUSTODY RECORD Address `/3r /-dal , i?A. <br /> Water Labs (please print) +j''r Phone No. _(261) Sty <br /> Proj. MgrXontact <br /> 0057 ; <br /> P.O. Box 4249 Ship samples to: , j Pink-Field Copy <br /> Modesto, CA 95352 1430 Carpenter Lane ;; white and Yellow•To Laboratory with Samples <br /> (209)527.4050 Modesto,CA 95351 Record of Yellow-ReturnIto Client <br /> PROJECT/SITE NAME: ANALYSIS REQUESTED <br /> roc Prc <br /> PROJECT CONTRACT/PO NO.: 1� <br /> P <br /> ME OF SAMPLER: REMARKSISPECIAL INSTRUCTIONS <br /> LAB USE ONLY SAMPLE <br /> LAB I.D. I.D. DATE TIME O ¢ CON- f\ ;, <br /> ` U � TAINERS <br /> la•L 2,0Y X <br /> a <br /> "Z 10.2 . i <br /> . t Q `;�;.4a ♦ � D <br /> • .' ;s.. ,. ,�"' ,fit?'0. <br /> RELMUISKM BY SIG DATEITIME RECEIVED BY SIGN DATEITIME,.a ttECIVED FOR LABORATORY <br /> �Q.A�c.&P9 w, <br /> BY(SIGN):CX,WPAte,, DATEIrIME •1 <br /> RECEIVED: <br /> t C COLD AND INTACT OTHER PRESERVATIVE ©YES\��y'�7�0 <br /> DOTHER: <br /> •TURN AROUND TIME: <br /> SHIPPED VIA: r-1 FED X OUPS ❑OTHER: SHIPPING ORDER NO.: `)°'` O24•Hr 02-Day 06-Day "--im-Day <br />