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California Water Labs <br /> P.O.SOX 4249 Ciient �` <br /> 1430 CARPENTER LANE Address 2735 '5y'm! <br /> MODESTO,CA 95352 <br /> PHONE(209)527.4050 Phone No. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> 7-cfL OD fie. ti a <br /> SAMPLERS (signs re} e o <br /> A Number Q tea, <br /> of � � r REMARKS <br /> StationCon- , <br /> Number Date Time � a Station Location tamers <br /> U i7 <br /> le( X1 1/70 C-. j')'q7,aj 00 <br /> XXA I 1 1 7 ?/ <br /> suo q x x I <br /> a. <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 /> i <br /> ' Company or Agency: Company or Agency: Company or Agency: Company or Agency. <br /> A. <br /> ' VDaWrwor <br /> ed by inature): Dcatre } Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> gene I' ` {signature} /. <br />