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Client i (IJI)A , a <br /> CSAMPLE CHAIN OF CUSTODY RECORD Address k c r <br /> Water Labs (please print) Phone No.(Z�4 <br /> 1033 Proj. Mgr.IContact <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> 1I <br /> t,:, alffornia <br /> Modesto, CA 95352 1430 Carpenter Lane white and Yellow-To Laboratory with Samples <br /> (209)527-4050 Modesto, CA 95351 Record of —i-\ Yellow-Return to Client <br /> PROJECTISITE NAME: XO' ANALYSIS REQUESTED - <br /> PROJECTICONTRACTIPO NO.: _ <br /> B11 J Til'17JO <br /> r i <br /> E OF SAMPLER: `U REMARKSISPECIAL tNSTRUGTIONS <br /> � tz� <br /> LAB USE ONLY SAMPLE d m NUMBER <br /> ¢ OF <br /> LAB I.D. I.D. DATE TIME O m CON- - <br /> O O TAINERS <br /> 9D-71 D ZIYI 25 1oc28 Z X 0 <br /> RELI UISH BY SIGN DATE/TIME RECEIVED BY SIGN DATEITIME RECEIVED FOR LABORATORY <br /> f D <br /> BY(SIGN SU OY DATE/TIME yo <br /> RECEIV <br /> CCOLD AND INTACT OTHER PRESERVATIVE DYES ONO <br /> ❑OTHER: <br /> TURN AROUND TIME: <br /> SHIPPED VIA: ❑FED X CUPS COTHER: SHIPPING ORDER NO.: 1724-Hr 112-Day 05-Day 1710-Day <br />