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California Water Labs ScM �d <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address y 3 1 Li - 1-4 H <br /> MODESTO,CA 95352 <br /> PHONE(209)527-4050 Phone No. S2 4 - 91e5 3 <br /> Contact Person '5c- <br /> n7`-CHAIN OF CUSTODY RECORD (please prinl) <br /> PROJECT NAME: <br /> SEM co/ <br /> SAMPLERS (signatur , n Number <br /> of L' � REMARKS <br /> Station o n Con- <br /> Number Date Time Station Location tainers C, <br /> u u L <br /> oSoy Ifyt'RS RO < tau <br /> G LO <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 /> Re in ished y(Zignature): Dilate / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Co any or Agency: 0 [io V (signature) Q/it GL <br /> C �Q� 7q(� ({ �� Pm <br />