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California Water Labs <br /> f. 'Z U) EAV I�J s�N ol) u <br /> I P-O. BOX 4249 Client <br /> 1430 CARPENTER LANE –q <br /> Address q'�03 PL-Y )'To <br /> _j MODESTO,CA 95352 <br /> r7 61: U-1 <br /> PHONE(209)527-4050 Phone No. & C <br /> Contact Person Etqv/N 'flA;))A U <br /> CHAIN OF CUSTODY RECORD <br /> (please print) <br /> PRO�f CT NAME:67 0 <br /> IQVMJ _5MbAU <br /> 17 <br /> SAMPLERS (signature) <br /> Number <br /> � <br /> of REMARKS <br /> Station <br /> Number Date Time E 100Con- <br /> o I- Station Location <br /> tainers <br /> qzl 6 3 H U_"/-L-f Shack 7,6 tv <br /> 57A1,1 P,e _P 1 0 L F <br /> ryz/� <br /> 5'41;y P06 0 o-1- n, i'D pt 6 <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): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Reli s d by(5y9na.ture): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> (signature) <br /> Comp or Agency: 9—t <br /> 9 � <br /> L q43 P <br />