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I <br /> m . <br /> I u <br /> 4'. <br /> California Water Labs <br /> P.O.BOX alas ) 0 P <br /> .� Client cJ <br /> 1430 CARPENTER LANEAddress y3l Af- 1 07c li - f <br /> MODESTO,CA 95352 <br /> PH0NE(2O9)527-4050 Phone llO. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> SAMPLERS (si at re) a / <br /> Number m <br /> / of 4��� �� REIARKS <br /> Station <br /> Numher Date Time U A S. . 'an Location Con- <br /> tamers <br /> ea <br /> • �=�� 23 ;J�, i ,� � � 3 �d6 3 <br /> �d3 33 ;J <br /> 3 3� '12 3 <br /> a3 Jo9 13 (f -3 3s <br /> k x- <br /> i3 c_. 3 32 <br /> 3Ile . )s <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: bate / Time IReceived by (signature): <br /> s Y . <br /> Company or Agency: Company or Agency: Company or Agency: Company or Apency: <br /> r <br /> Relinquished by(signature): Elate / Time Received for Laboratory by: Date / Time Renarks/Shipping Information <br /> any S .r <br /> 9Agency" <br /> or // <br /> I <br /> II f, <br />