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California Water Labs ' <br /> P.O.BOX 4249 r Client <br /> 1430 CARPENTER LANE p k Address 3k <br /> ^' MODESTO,CA 95352 <br /> tiWONE(209)527.4050 Phone No. Shy —161Y3 _ <br /> Contact Person r <br /> CHAIN OF CUSTODY RECORD (please print) <br /> �� RaaECT,.HAME .. <br /> i`60 <br /> RS signature <br /> Number <br /> ' of REMARKS <br /> -st'at'ion -- <br /> Number Date Time R Station Location Con- <br /> a, tainers <br /> lo' UM . '%T !o X X y34-5' <br /> shl I V I <br /> $ i$ w-a 2 -�>5 X X 7D <br /> 5111 2'. �" — - x X m ire 73 <br /> is )i " kXX <br /> 8 2:� 1-7 <br /> by(sig ture): Dat / Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> �a�/ar Agency: �� <br /> Company <br /> Com any Company or Agency: Comor A ency �y3 : <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by: Date / T' Received by (signature): <br /> Company or Agency: _ Company or Agency: Company or Agency: Company or ncy: <br /> Relinquished by(signature): Hate / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Company or Agency: - - _� signature � 3'�-7 <br /> I r �� A <br />