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California Water Labs ,, �� <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANEAddress q.3z ��'�� 'w bq 69-0MODESTO,CA 95352 ��p C✓2v�/_��� <br /> PHONE(209)5274050 Phone No. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> I <br /> SAMPLERS (signature Aven Number <br /> { i Q <br /> of •� REMARKS <br /> Station <br /> Number Date Time A Station Location Con- `L�r <br /> tainers i 111 <br /> l ;to N Z y(�> <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 /> heddb signature): Date / Time Received for Laboratory by: Date / Time Remi� /Cr�ks/Shi�ppi�ngIIYnInformation <br /> signature) <br /> n <br /> si}`na�tu�re)� encY: >� : L;if <br /> L <br /> / <br />