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Client STGr <br /> California S MPLE CHAIN OF CUSTODY RECORD Address <br /> Water Labs (please print) Phone No. <br /> Proj. Mgr./Contact <br /> tr" Modesto, <br /> P.O. Box 4249 Ship samples to: Pink-Field Copy <br /> 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 REQUESTED <br /> 0` F K1Po.J /a 9D Som <br /> PROJECTI ONTRACT/PO N -. <br /> NAME OF "ER: REMARKSISPECIAL INSTRUCTIONS <br /> LAB OSE ONLY ' SAMPLE f mQ NUN BER -� 1 <br /> LAB I.D. I.D. DATE TIME o ¢ CC N- h / <br /> U TAI ERS <br /> (177 X -� <br /> J , <br /> o <br /> RELINQUISHED BY SIG DATEITIME RECEIVED BY(SIGN) DATE1TfME RECEIVED FOR LABORATORY <br /> BY(SIGN):-- DATEMME <br /> RECEIVED: <br /> ❑COLD AND INTACT OTHER PRESERVATIVE DYES I NO <br /> ❑OTHER: <br /> - TURN AROUND TIME: <br /> SHIPPED VIA: []FED X ❑UPS ❑OTHER: SHIPPING ORDER NO.: 1124-Hr 112-Day \t�-Day E10-Day <br />