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California Water Labs <br /> P.o.Box alas Client <br /> 1430 CARPENTER LANE Address 4/3 / w • HA7'LH IE'D . (M(Mot)C57MODESTO,CA 95352 52 /�7 <br /> ` PHONE(209)527-4050 _ Phone No. <br /> Contact Person 5Co71— <br /> CHAIN OF CUSTODY RECORD (please print) <br /> 'i PROJECT NAME: SEM (�G/ <br /> _9 <br /> �O <br /> SAMPLERS (signatur Number <br /> 17 L lJ of REMARKS <br /> �Q �� <br /> Station <br /> Number Date TimeStation Location Con- <br /> tainers <br /> os'o7 .1 vt-P5 Ao cAcaN i <br /> g„$ 10 �( XX I <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 1n fished i nature Date / Time Received for Laboratory b Date <br /> i Y(i 9 )� Y y: / Time Remarks/Shipping Information <br /> Co any or Agency: 5iQ U (signature) <br />