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California Water Labs <br /> P.O. BOX 4249 Client <br /> 1430 CARPENTER LANE S <br /> MODESTO,CA 95352 Address <br /> PHONE(209)527.4050 Phone No. KM <br /> s <br /> Contact Person T- cJ <br /> CHAIN OF CUSTODY RECORD (please print) rn Q <br /> mss® Lo w <br /> PROJECT NAME: Uj <br /> U? <br /> w � <br /> J l— <br /> �l — <br /> D O z L <br /> S RS J( nat#ure) : <br /> wNumberof ^ REMARKSStation Number DaStation LocationCon-tainers <br /> 7- <br /> -t 2:o b 2- <br /> 38 <br /> 7 ) Z: P- 1 rf7 I aohme3 <br /> esh �sure): Zte Time Received b <br /> y (signature): Relinquished by(signature): [ate Time Received by (signature): <br /> an or <br /> Com AVmy,.pen y: -m-6i Company or ' <br /> Company or A enEy: Company or Agency: <br /> 3: <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / Time Received by (signature): <br /> Company or ncy: Compan gency: Company or Agency: <br /> Company or Agency: <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Company or Age (signature) <br />