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California dater Labs ClientSt0�xto"J SfRVitE St�9rroti <br /> P.O.BOX 4249 <br /> 1430 CARPENTER LANE Address pa (3o It 5 0 8 <br /> MODESTO,CA 95352 Phone No. <br /> 4& y — 3 3-3 �•• <br /> PHONE(209)527-4050 <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (ploaae print) <br /> PROJECT NAME: S700JJ AJ SE R U i c E 57/4 T/o ti �-� <br /> StOCRION oLiC EtaFT/ 1�yi� �� <br /> SAMPLERS (signatur Number �F9oa j <br /> • of �/ (� REMARKS <br /> Stationc a r�0 \h f i <br /> Number Date Time L Station Location Con 0 � � <br /> �, tainers <br /> 6'/S � �� E• MRRKe:t 5T• I <br /> 1 / s l r .) Y <br /> SA pct�AR►rE, ��s7«•�..a ° ,.,a,,l. -I y� �7 , I <br /> SAM P L 6 i=(3.1 / <br /> � 1 <br /> 0 lql�5( <br /> Y <br /> i <br /> .i. i <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): i <br /> Company: or Agency: Company or Agency:' Company or Agency: Company or Agency: +i <br /> f 1 <br /> Requsshed (signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> C nnyy oor++ Agency: 9� 3'4f (signature) 3: 0 � <br /> v i <br />