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California Water Labs <br /> P. O. BOX 4249 Client _ �`�;�\-�� A`1 <br /> 1430 CARPENTER LANE Address 4� I �) wr ` w� ppf- K v <br /> MODESTO,CA 95352 ` ?-�)�k'�F; <br /> PHONE(209)527-4050 Phone NO�� 't1 <br /> Contact Person l .' <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: L)T <br /> �i A`L�f D� "Y' �.�'� C�i�l�•,O N yD t`f" .. <br /> SAMPLERS (signature) Number Q� i <br /> D e <br /> REMARKS <br /> of <br /> Station - 1 <br /> Number Date Time A - Sta n Location C0"- <br /> tainers <br /> -" y V14 zZ5 , z 5T _ <br /> Relinquished by(signature)i Date / Time, Received by (signature):; Relinquished by(signature). Date / Time.- -Received by (signature): <br /> F i <br /> Company or Agency�f� /� Company or Agency:.--r Company or Agency;1" ' /� Company or Agency: <br /> Relinquished by(signature); Date / Time Receivedby (signature): Relinquisbea by: ffate / Time Received by gnature): <br /> Company or Agency - Company or Agency: Com�ny or Agency: Co or Agency: <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Comp n br enncy, <br /> (signature) <br />