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Client - <br /> SAMPLE CHAIN OF CUSTODY RECORD Address <br /> ©ItfOrnia lease print) <br /> Phone No. <br /> g Water Labs (p p Proj. Mgr./Contact <br /> 1294 <br /> I P,O. Box 4249 Ship samples to: Pink• Field Copy <br /> � p ' White and Yellow-To Laboratory with Samples <br /> Modesto, CA 95352 1430 Carpenter Lane Record of Y0ow- Return to Client <br /> (209) 527-4050 Modesto, CA 95351 <br /> PROJECT/SITE NAME: " ANALYSIS REQUESTED <br /> PROJECT/CONTRACT/Pd NO.: <br /> REMARKSISPECIAL INSTRUCTIONS <br /> NAME OF SAMPLER: 1U <br /> LAS USE ONLY SAMPLE 6 m NUMBEROF <br /> LAB I.D. I.D. DATE TWE 4 ON- <br /> O C7 TAINERS j <br /> n 'k <br /> 11 JX X <br /> RELINQUISHED BY (SIGN) <br /> DATE/TIME RECEIVED BY (SIGN) DATEITIME RECEIVED FOR LABORATORY <br /> BY (SIGN): DATEJTIME <br /> f <br /> RECEIVED: <br /> DCOLD AND INTACT OTHER PRESERVATIVE i-'YES `NO <br /> ]OTHER: <br /> TURN AROUND TIME: <br /> 724-Hr L2-Day �15-Day C10-Day <br /> SHIPPED VIA: --FED X ❑UPS ❑OTHER: SHIPPING ORDER NO.: <br />