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California Water LabsC11entST�"er6u Sr�Vlc� S�riaN <br /> P.0.BOX 4249 Pdr OX.�0�' pC' �� �•S��` , <br /> 100 CARPENTER LANE Address � y�U „ �3 <br /> MODESTO,CA 95352 Phone No. <br /> PHONE(209)5274M Contact Person <br /> T CHAIN OF CUSTODY, RECORD (plea"Print}. <br /> - X, <br /> PROJECT h1WE: . 1 <br /> JIMCWDN S �U���- sr�T16N " a <br /> J <br /> SAWLERS (signature) f ' Number <c�� REMMS <br /> of <br /> Station Con- <br /> Number Date Time � w Station Location taint; <br /> v ca <br /> 419 Y <br /> il1h� �. r / nti SRM PLEA 1 D 1 t 1 <br /> k <br /> a, <br /> U <br /> • r <br /> - <br /> - - si nature): <br /> Relinquished by(signature): Date / Time Received by (signeture�: Rel -by(slgnature-}; -Dade- /. lime Received by ( g <br /> Company or Agency Company or Agency: Company or Agency: <br /> Company or Agency; <br /> Relinquisher.d by(tignature): Date 1 •Time Received by Relinquished by: Date <br /> (signature)i Relinq /'Time Received by (signature); <br /> r. <br /> Company or Agency: <br /> Company or AQenty:' Company or Agency: <br /> Company or Agency: <br /> 2ein�Yfis_hed �siggnature): Date 1 Time Received for Laboratory by: Dte J Time Remarks/Shipping Information <br /> n=isgnat rany-or Agency; Pn. <br />