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California Water Labs iN��c,� L)A <br /> P.0.BOX 4249 Client / .)I <br /> 1430 CARPENTER LANE Addresses <br /> MODESTO,CA 95352 �f7 3 '3 S-95 <br /> PHONE(209)527.4050 Phone No. <br /> CHAIN OF CUSTODY RECORD Contact (ple se print) <br /> PROJECT rNAME: <br /> SAMPLERS (signature) <br /> }} Number <br /> of <br /> REMARKS \ �' <br /> Station Con- <br /> Number Date Tine Station Location tainers <br /> Sy/dad V '449 h 13U 6 p <br /> r+ SAnVLE t! 1-�L w wFsT f►�� ( / PQ# y7 6 d 6 <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 Agedcy: <br /> Rel u hed by ignature): Date / Time Received for Laboratory by: Date /pTime Remarks/Shipping Information <br /> Co any or Agency: �/p /•S/d ignature) <br />