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California Water Labs "--em C) <br /> P.O. BOX 4249 Client �7 <br /> 1430 CARPENTER LANE Address y9 C"`�• A?� <br /> MODESTO,CA 95352 S <br /> PHONE(209)527-4050 Phone NO. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: CiE/7J(�O <br /> 7a s vY <br /> SAMPLERS (signature) c: o Cj <br /> Number It:Qz <br /> 1 \G \ REMARKS <br /> of <br /> Station <br /> Number Date Time A Station Location Con- <br /> tainers <br /> 72s `ft "3° Yj 225- f, AU UASTE o <br /> J Z <br /> 1< r , <br /> cn�' 6;:'i� • <br /> J- fril <br /> C)1 k <br /> RelinquisWd-gy(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 b (si nature): 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 /> Relinquished b ignature): Date / Time Received for Laboratory by: TDate '.,Time Remarks/Shipping Information <br /> Company or Agency: 57 <br /> (signature) [S <br />