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uaiitornia eater Labs Client SP U <br /> P.O. BOX 4249 �� • r7�-Zti' , /yooe rk' <br /> 1430 CARPENTER LANE Address _ 9/jf7 <br /> MODESTO,CA 95352 Phone No. 5 L �y�oS3 <br /> PHONE(209)5274050i C <br /> Contact Person 5 r� <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> / ..� /7�O�rldv► » D �0 <br /> h CD J J1A`' <br /> S RS (signature) 1 Number Q°Qi 1 REMARKS <br /> C of <br /> Station a a Con- v <br /> Number Date Time o Station Location tainers <br /> � 1 <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature). Date / T!me Received by (signature): <br /> Company or Agency: Company Agency: Company or Agency: (Company or Agency: <br /> p y or gey' <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 /> nqui eft by iDat / Time Received for Laboratory by: Date / Time ( Remarks/Shipping ;,iformation <br /> j /J 7� /_b (signature) <br /> e mp n y or <br /> r J y: <br />