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California Water Labs �� wFsM6AJ srdN� <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address <br /> MODESTO,CA 95352 - Phone NO. <br /> PHONE(209)5274050 <br /> COntactPerson <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <`!"MC-O/wE <br /> SAMPLERS (signature) I Number QI? <br /> of REMARKS <br /> Con �O� <br /> Station a a C <br /> Number Date Time Station Location �� y? <br /> U ,� tainers <br /> $ 0.011 <br /> ✓ /9�� L oa7N EAT D. <br /> SO I L SFWL 1 ���U� <br /> Z �fr ps 4/4 F Lq!F116F� 11 r' C � Cc/AT� S11/hp�t f Cflc(S13 <br /> AM ilk WAtt <br /> i <br /> 5 <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 /> _Cofipany or Agency: Company or Agency: Company or Agency: Company or Agency: <br /> Rel nq hed�&(s4gnature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> . C any or gencA— y:'" (signature) �,�, <br />