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California Water Labs t. <br /> a� <br /> P.O.BOX 4249 Client s �C. �::.;. 1430 CARPENTER LANE q31+ <br /> Address <br /> c>> 4 MODESTO,CA 95352 SZ — <br /> (yS3 <br /> PHONE(209)527-4050 Phone No. <br /> r; "A w Contact Person Ta-r m n <br /> CHAIN OF CYSTODY RECORD (please pant) <br /> PROJECT'NAME: <br /> 5WO X 157 k• it Tra y va <br /> _ <br /> SA jnature) <br /> i <br /> Number �m <br /> REMARKS <br /> of <br /> Station ` (w <br /> Humber Date Time CL .0 Station Location Con- <br /> ,._--•--- :tamers' <br /> 18 a7 X lank 3 `9d 71137-5 <br /> S/ S 1z' -rank'to Fast -So,' X X 7C <br /> (8 <br /> XL&A 46 Whof I x x7� <br /> X 1k- I/ t'w5� 6jr 1 7� <br /> 00 S9i) <br /> �wA I Vo <br /> R,:.l4nga 72d b ignature):Comm /. Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> Comp y�r Agency: 3� Company or Agency: Compiay-or Agency: <br /> (ravrAency: <br /> Relinquished by(signature): Date / Time Received by (signature): ' Relinquished by: Date. ./, Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Apen y <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/shipping Information <br /> Company or Agency: – —._.___ t(signature)� 4�/ �3 1�Pr i'� {, ��f:, ;n r�, rrf <br />