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121 <br /> s <br /> 'California Water Labs <br /> Client <br /> P.O.BOX 4249 ( <br /> 1430 CARPENTER LANE Address ! <br /> MODESTO,CA 95352 Fhone No- ---------- <br /> � <br /> PHONE(209)527-4050 Contac!Person <br /> CHAIN OF CUSTODY RECORD (please print} <br /> PROJECT NAME: r - , <br /> SAMPLERS (signature) klswer <r�a /`` REHAAKS _ <br /> of \� <br /> "on A Station location Can- <br /> Number Date Tim tai <br /> 5 ners ti \ <br /> I 11r� <br /> z <br /> y� <br /> Cl <br /> Ya. <br /> 1. <br /> A <br /> / Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> Relinquished 6.y(signature): Date a <br /> - Company or Agency: Company or-Agency: Company or Agency: <br /> Company or Agency: d <br /> e Received by (signature): <br /> Relinquished by(fignature): Date / Time Received by (signature): Relinquished by: <br /> Date / Tim <br /> Company or Agency: <br /> Company or Agency: Company or Agency: Company or Agency: <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date I Time Remarks/Shipping Information <br /> ture) <br /> �pany or Agency.. / 1 1ft <br /> M <br />