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California Water Labs <br />P. O. BOX 4249 Client V <br />1430 CARPENTER LANE Address- 0 <br />MODESTO, CA 95352 <br />PHONE (209) 527-4050 Phone No. <br />Contact Person -,)(,7 1'ke— <br />CHAIN OF CUSTODY RECORD (please print) <br />PROJECT NAME: %.z (n <br />Number <br />of <br />Con - <br />tainers <br />REMARKS <br />SAMPLERS (signature) <br />Station <br />Number <br />Date <br />Time c'Q <br />Station Location <br />10a ;P),a), <br />X <br />X <br />343 SY Sr): <br />r � <br />4-4- <br />tj 3 <br />4(o &jo-4-r- S0,14" <br />ir I e) <br />j. <br />47 <br />21� - <br />7— <br />4-17 <br />4-q <br />Relinquished by(signature): Date Time Received by (signature): <br />Company or Agency: Company or Agency: <br />Relinquished by(signature): <br />Company or Agency: <br />Date Time <br />Received by (signature): <br />Company or Agency: <br />Relinquished by(signature): Date / Time Received by (signature): <br />Company or Agency: Company or Agency; <br />Relinquished by: <br />Company or Agency: <br />Date / Time <br />Received by (signature): <br />Company or Agency: <br />Relinquished by(signature): Date / Time Received for Laboratory by: Date /Jime <br />(signature) <br />Company or Agency: <br />Remarks/Shipping Information <br />0 <br />• <br />