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Client 1U«t'J,bA _Ajj()sfrkf <br /> AlkCalifornia SAMPLE CHAIN OF CUSTODY RECORD Address /Oyi S- c,;4 <br /> Water Labs (please print) Phone No. <br /> I / / 101 Proj. MgrJContact k a ��4�` <br /> P.O. Box 4249 Ship samples to: 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-Return to Client <br /> PROJECT/SITE NAME: Q _ ANALYSIS REQUESTED <br /> 11 d 4 Gt�slr Ld <br /> PR JECTICONTRACTIPO NO.: � �O <br /> NAME OF S MPLER: LM REMARKSISPECIAL INSTRUCTIONS <br /> 0, f"i <br /> LAB USE ONLY SAMPLE I <br /> � < INUMOBERR <br /> LAB I.D. I.D. I DATETIME O ¢ CON- <br /> 0 O TAINERS <br /> M it 2 °oI;� I-r-s �:3 X 2 X X X Weil <br /> Irl. 2,°I >uF f-Zti r,y k 2 X X �' s� &10 <br /> • ,iL <br /> r'• <br /> UISHED BY SIGN DATE/TIME RECEIVED BY SIGN DATE/TIME RECEIVFA FOR LABORATORY <br /> 1Y., t,� O BY(SIGN): DATE/TIME <br /> RECEIVED: <br /> LD AND INTACT OTHER PRESERVATIVE DYES ONO <br /> ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X ❑UPS ❑OTHER: SHIPPING ORDER NO.: 1124-Hr 02•Day Day D10Day <br />