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California Water Labs F` <br /> P.0.BOX 4249 Client <br /> 1430 CARPENTER LANE Address �T _�o_�D l k'ns' STO){C�k-tF <br /> MODESTO,CA 95352 <br /> PHONE(209)5274050 Phone No <br /> Contact Person —F'r7a— <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME LiT� TRA _ <br /> SAMPLERS (signature) c' o <br /> Humber Q Qa. <br /> ofM REMARKS • <br /> Station <br /> Number Date Time A Sta n -Location Con- �� - <br /> _ tainers <br /> i t1- \' - <br /> N 14 az 5T - <br /> Relinquished by(signature Date / Tim Received by (signature): Relinquished by(signatur Date / Tim Received by (signature): <br /> Company or Agency: - Company or Agency;. Company or Agency: - Company or Agency: <br /> Relinqui hed by(signature ,t` Date x <br /> Time " Received (signature): Relinquis by: ate / Time Received by fignature): <br /> C m any or Agency: / Company or Agency: Comp6-5110 r Agency: Company or Agency: <br /> Reelliingqu,is..,,hppedby(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> C;p, n 'vrxA en _ Tj�)>{ L _ (signature) - <br /> �, y• 1 115 � 5 ,` i jl <br />