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California Water Labs O( <br /> t P.0.BOX 4249 Client 3A y 'sC n Co - T_ �UC7La iJ <br /> 1430 CARPENTER LANE Address??30 C tfffNf 126 fAI/� <br /> MODESTO,CA 95352 <br /> PH0NE(209)527-4050 Phone No C9/6I 9C- 7- 242 4 <br /> Contact Person IBEX <br /> CHAIN OF CUSTODY RECORD (please print) <br /> 1 PROJECT NAME: (1955E7T- rotj 5T-R vc"p 0 A41 lr <br /> SAMPLERS (signature) o? `� <br /> ( 21,f 01V� Number Q�v, r; <br /> i of (y (i REMARKS <br /> Station <br /> Number Date Time u Station Location Con- <br /> tainers <br /> v1 spiny�j # 5t>v H r:No � S(LVER USt� <br /> U <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 /> Rel ' qu shed by gnature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> C any or Agency: �� 5.3° (signature) `(a <br /> C uc L �PY F'� <br />