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California SAMPLE CHAIN OF CUSTODY RECORD Address 4,49, <br /> Wafer Labs (please print) Phone No. 9::-5�' ` — 3 -"z Z <br /> Proj. Mg./Contact <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> OModesto, CA 95352 1430 Carpenter Lane - White and Yellow-To Laboratory with Samples <br /> (209) 527.4050 Modesto, CA 95351 Record of/_ Yellow-Return to Client <br /> PROJECT/SITE NAME: ANALYSIS RECUESTED <br /> PROJECT/CONTRACTIPO NO.: $ ' <br /> ` MAY 2 9 40n-) 1 d <br /> ME OF SAMP / �( v� @W ROPP91011I�}11IA�'�1L7-iTLIR <br /> r i(C I PFRP, IT/SERVICES <br /> LAB USE ONLY SA u m NUMBER �/ y <br /> OF <br /> LAB I.D. I.D. DATE TIME O 2 CON <br /> - <br /> O c7 TAINERS <br /> L Th 22� vj0 <br /> a 'KxTI yo - <br /> C, <br /> X <br /> RELINQUISHED BY SIGN (�DATETIME _ RECEIVED BY SIGN DATE/TIME CEIV D FOR LABORATORY <br /> ^y'96 BY(SIGN)G DATErnME T <br /> RECEIVED: <br /> OLD AND INTACT OTHER PRESERVATIVE OYES NO <br /> DOTHER: <br /> TURNAROUND TIME: <br /> SHIPPED VIA: DFED X CUPS ❑OTHER: SHIPPING ORDER NO.: 024-Hr 02-Day 05-Day N, <br /> O-Day <br />