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California Water Labs fx <br /> P.O.BOX 4249 Client cJk. <br /> 1430 CARPENTER LANE Adds ofv <br /> SbK -§60v <br /> MODESTO,CA W52 phone Na <br /> PHON E(209)527.4050 <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> SAMPLERS (signature) c a <br /> n Number Q <br /> VMap of <br /> REMARKS <br />`f Station `1 Con- <br /> Number Date Time o b Station oca't�ian. <br /> a tainers <br /> rabeWa 9 x xi <br /> Closen <br /> �b <br />�- Reli he (si na ure): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received by ($Agnature). <br /> G) <br /> ny or gen Company or Agency: Company or Agency: Company or Amey: C] <br /> P y9 t, <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received by (sdgatur`e?: <br /> Company or Agency: Company or Agency: Company or Agency: Company or Age ri 4- <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information 5 <br /> /n <br /> Company or Agency: (signature 1 L �6 <br /> �� <br />