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�Ual i forn is Water; Labs y: Y <br /> P.O.BOX 4249 <br /> 1430 CARPENTER LANE Client <br /> MODESTO,CA 95352 Address 3 _ <br /> PHONE(209)527-4050 Phone No. - ui <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: IUj UJ <br /> h &7 �L <br /> LW <br /> A ;VD 741DI� O z <br /> kW& RS ( nature) : ' 'o' z w <br /> Number 'IF w, �'" CIT <br /> - <br /> of REMARKS <br /> Station U <br /> Number . Date Time OL <br /> Station Location tamer: N <br /> 7-11 t5v <br /> Relh by si nature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received b <br /> genlfy �by ,/�� y (signature): <br /> an r Company or llznejw ~ Company or A enEy: Company or Agency: <br /> Relinquished by(signature): Date / Time Received by (si ature): Relinquished by: Date / Time Received b <br /> /- % y (signature): <br /> Company or ncy: Compan gency: Company or Agency: Company or Agency: <br /> Relinquished by(signat re): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Company or Agen (signature) ./_(qt--�y <br /> • SIX �. .• <br />