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California Water Labs <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address Z73S �� PEE .Su� L— <br /> MODESTO, CA 95352 <br /> PHONE(209)527-4050 Phone No.9U z <br /> Contact Person j� G <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> z4"d <br /> 5 tERO(signature) c' o <br /> * / Number e z <br /> o f REMARKS <br /> a 1 N <br /> Station- Con- <br /> Number Date Time q Station Location tai Station <br /> u <br /> X010 4 � / �u71/ ?� X 5/�9 <br /> c 0 �- 17r� t' IV6t-YN �7Vt7 X .Y X b <br /> 005 1 X VA—A)k �rw )v,J l X A X I l <br /> WS-1 „ z No-m cam,- i K <br /> �9:� Id-7,u vvn lYI <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 /> Relinqulshed`Gyv(sign ature): 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 /> � .9 <br /> • <br /> _gng{eit�s/homed /3�qn dire) D to / Time Received for Laboratory by: Date / Time Remarks/Shipping Information 0 <br /> ompany orAgencY (s, ture) 1 7 (f4rl /I' <br /> 0e. . �' / i /S r Pw; <br />