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California Water Labs <br /> P.O.BOX 4249 Client <br /> 1430 CARPENTER LANE Address - 2- - ,2X S:2! <br /> MODESTO,CA 95352 ,33 ?� ���Z�•j <br /> PHONE(209)527-4050 Phone <br /> ContacttPerson <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: <br /> �j <br /> 5 LE (syip ature) _ Number Q� i <br /> Oily / <<L'/�L�' of REMARKS <br /> ton <br /> Numbember Date Time o b Station Location Con- <br /> . tainers <br /> vu Z l �2 8O -1 <br /> Relinquished by(signature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> Company or Agency: Company or Agency: Company or Agency: Company or Agency: <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 Agency: <br /> R in uishe by �igna e): Dat / Time Received for Laboratory by: Date / Time Remarks/Shipping Information <br /> �i (signature) <br /> _ <br /> pane epdyi Uc� 355 <br />