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r <br /> r <br /> r <br /> Client <br /> Calffo `nia SAMPLE CHAIN OF CUSTODY RECORD Address <br /> 1 J g*ater Labs (please print) PhDne No. a-9 5 d o J <br /> 22 <br /> n Proj.MgrJConlact 5C <br /> P.O.Box 4249 Ship samples to: <br /> fi'«•, u, <br /> Modesto,CA 95352 1430 Carpenter Lane i Pink-Field Copy <br /> (i 09)527.4050 thodesto,CA 95351 Record 1 of White and Yellow•To Laboratory with Samples a <br /> Yellow•Return to Client <br /> PROJECTISITE NAME: <br /> V ANALYSIS REQUESTED <br /> PROJECTICONTRACTIPO NO.: Zt <br /> NAME OF SA LER: <br /> REMARKS/SPECIAL�- INSTRUCTIONS <br /> LAB-USE SA P � a NUMBER <br /> LAB 1,D. it i.0. DATE TIME O CON• <br /> I yj <br /> U U TArNERSTgo 1a� - <br /> � Aad.L-T A-4 K <br /> x rt <br /> IF.TR 1551 �. <br /> 41 ,t <br /> 1 i3 <br /> \ tl rl <br /> y <br /> St u (53°IX 3 K <br /> 511 <br /> Ib <br /> •�E <br /> RELINQUISHED BY SIGN DATEITIME RECEIVED BY SIGN DATEITIME • <br /> RECEIVED FOR LABORATORY <br /> BY(SIGN): �.,�� J f'LL���»1 DATEITIME- J�_X110 <br /> I <br /> RECEIVED: y <br /> 1 <br /> • KCALD AND INTACT OTHER PRESERVATIVE ❑YES ❑ND <br /> 5 3690 7& DOTHER: ; <br /> TURN AROUND TIME: <br /> 3 . <br /> SHIPPED VIA: _iF DX CUPS `if QTHER:_ SHIPPING ORDER NO.: 024-Hr C2-Day p,SDay C iQ Day y <br /> i <br /> li ,I al <br />