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: <br /> 1 a <br /> '.F <br /> jK <br /> } <br /> �alif orn ia Water Labs <br /> P.O.BOX 4249 �etkotl (&wd"'t-- c-lR . 4Ika � <br /> fu lr� <br /> 1430 CARPENTER LANE <br /> MODESTO•CA 95352 I:ddraes <br /> PHONEi209)527.4050 Phon®No. ~� , <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> i <br /> PRD E KAtI>: <br /> r�1 C�f+Tfaan .MD <br /> SAlVLEIt s nett ) Y, 1� � *�a <br /> • l4uzber ��vQ FUdfKS <br /> Station of RE <br /> Rueber Daae Time '� 5tatian Location tamers <br /> T r �3 <br /> 33 <br /> Cf� � <br /> z,. <br /> r X • <br /> 37 <br /> f Y 3 <br /> f `\ <br /> ( 3. <br /> F <br /> ( t4 <br /> bTat r/ Tj Received by (signature): Relinquished by(signaturc): date Time Received by (signature). k <br /> ? <br /> ■ �'- C !�J Company or Agency: Company or Agency: Cor�any or Agency: <br /> Ufa i <br /> Relinquished by(iipnature): Date / Time Received by (signature): Relinquished by: Date / Time Received 6y (signature): , <br /> Company or Agency: Cowany or Agency:' Company or Agency: Company or Agency: <br /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> Company or Agency: (signature) <br /> l _ <br /> l <br />