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California Water Labs <br /> P.o.BOX 42as Client )6IDwILL1(VC5TFAN MfRR <br /> 1430 CARPENTER LANE Address L2J GRANT / SJocK toN c4•g5;207. <br /> MODESTO,CA 95352 <br /> PHONE(209)527-4050 Phone No. 3 ) <br /> Contact Person PIL4— <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: &00 W I E L/v,G�.TER N MCTE A- �V <br /> SAMPLERS (signature) cr <br /> Number Q x <br /> jv-e-aiof Q '� � REMARKS <br /> �\ �0 �\ w <br /> Station o a r 'y' Con- <br /> Number Date Time Station Location tainers <br /> A /29 QWm ST. 77K• c y�W <br /> TANI��(I,l 8 «AsAMnc qtr �• raNKi l) a Cwt -ovrNia�E�< ,s Eyre soi <br /> ) 'qo 1q GRAurSY tK. �� y „ 0� <br /> AN 7 <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date / lime Received by (signatu@ - d <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency:3 c c <br /> 3 <br /> 2 LV <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received by (signar�j: -> <br /> r <br /> Company or Agency: - Company or Agency: Company or Agency: Company or Agency:n = LO <br /> Rel ' shed (signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information = �, <br /> (signature) <br /> Co "array or <br /> Agency: <br /> w JA <br /> i <br />