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California Water Labs <br /> P. O.BOX 4249 Client <br /> 1430 CARPENTER LANEMODEAddfeSS e� <br /> )5 95352 <br /> PHHONEONE((200 9)527-4050 Phone NO. <br /> SOn <br /> CHAIN OF CUSTODY RECORD Contact P(ple se print) <br /> PROJECT NAME: <br /> ✓✓ N <br /> SAMPLERSsi nature <br /> ( ) <br /> Number Q Q� <br /> of / .�G] REMARKS <br /> Station L <br /> Number Date TimeA Statton Location Con- <br /> u tainers <br /> i <br /> L <br /> f <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received by.. (signature) 4, <br /> c, <br /> Company or Agency: Company or Agency: Company or Agency: Company oE�Agency:', <br /> y l <br /> Relinquished by(signature): f,re): Date / Time Received by (signature): Relinquished by: Date / Time Received bynatune�: <br /> l <br /> Comparvy--'Agency: Company or Agency: Company or Agency: Company or Ap��, t u� <br /> �Le �jjI/ <br /> �n,9} pature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> CoZ�670 1 (signature) <br /> P .-17 <br />