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California Water Labs <br /> P.O.BOX 4249 Client GOOD w'CL 7/N,�7SUS T& y <br /> 1430 CARPENTER LANE Address 129 "j' �rYCAtJ7— ST, 7K �) <br /> MODESTO,CA 95352 Phone No«°9 <br /> PHONE(209)5274050 <br /> Coritect Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: �v <br /> _ O <br /> GOO Dt�/6c lA/Dvs/7h'y417 <br /> SAMPLERS (sign tur / Number 1?z v <br /> - A C � Q.of (,Q REMARKS <br /> Station o a Con- G OQ <br /> Number Date Time Station Location tainers <br /> U U' <br /> I/,lS V A P E .) SOW'y END <br /> h SHTPLE 2, IN &:V l <br /> Relinquished by(signature): Date / Tim: Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> i Company or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> RelinSuished by(signature): Date / Tini: 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' ui ed by('53� i�� atv re): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Co ny or AgenE?' T1� (signature) l OJL �j,�(���YV� <br />