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f <br /> California Water Labs <br /> P.O.BOX 4249 Client n <br /> 1430 CARPENTER LANE Address <br /> MODESTO,CA 95352 <br /> PHONE(209)527.4050 Phone No. <br /> Contact Person <br /> CHAIN OF CUSTODY RECORD (please print) <br /> PROJECT NAME: RECEIV <br /> SAMPLERS (signature) ' P JUN 8199 <br /> Number <br /> of 01"ONMENTA L H 'ALTH <br /> Station <br /> PERM IT/SERVIC <br /> Number Date Time 'R Station Location tp tamers <br /> t-z, -f T 2 <br /> 2 fa <br /> r Relinquished.by(signature): Date / Time Received by (signature): Relinquished by(signature): Date / Time Received by (signature): <br /> ti <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 /> Relinquished by(signature): Date / Time Received for Laboratory by: Date / Time Remarks/Shipping information <br /> (signature)I S 1l� <br /> pa yi or AgE►��- L ` : '/ IG j. �9 / / r�/` <br />