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California Water LabsS747/o� <br /> P. O. BOX 4249 Client S <br /> 1430 CARPENTER LANE Address <br /> M0DEST0,CA95352 Phone No. - <br /> PHONE(209)527-4050 <br /> Cohtact Person <br /> CHAIN Of CUSTODY RECORD (please print) <br /> PROJECT NAME: )70CK70,V KF S7A , <br /> '2085/ SIFIC/FF -ESC�9C0i✓ <br /> N y V <br /> T J <br /> SAMPLERS (signatureT : q � Number <br /> MARKSK <br /> \� <br /> / r <br /> _z_ ��istl��1� RE <br /> oP <br /> Station [111� `') <br /> �v <br /> Number Date Time c Station Location tainers (� 1V <br /> v ca <br /> �10851 �cd ASSI ",yTUF, � <br /> _ D G /J-OC I'W- <br /> Relinquished by(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 by(signature): 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 /> inq fished by(si ): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> n <br /> Lom � jt 7! (signature) <br /> '_ �4tge y _� pp <br />