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Client ��'i-�J(z C— "j, <br /> tCalrfornia SAMPLE CHAIN OF CUSTODY RECORD Address `t '`� F ST snCQA. CA <br /> ` 'Water Labs (please print) Phone No. 91(O 55Z - \3111 <br /> go, I , 1745 Pray. Mgr.lContact . A L W A Q <br /> LI-1 I <br /> P O Box 4249 Ship samples to Pink Field Copy <br /> Modesto, CA 95352 1430 Carpenter Lane 1 I White and Yellow To Laboratory with Samples <br /> (209) 527 4050 Modesto, CA 95351 Record of Yellow Return to Client <br /> PROJECTISITE NAME ANALYSIS REQUESTED <br /> LoD 1 C ANNE RY <br /> PROJECTICONTRACTIPO NO <br /> PC"P • <br /> NAME OF SAMPLER REMARKS/SPECIAL INSTRUCTIONS <br /> C;OZ'boo Al-wgR] r, <br /> LAB USE ONLY SAMPLE (L NUMBER <br /> a OF r" <br /> LAB I D ID DATE TIME 0 CON <br /> U TAINERS <br /> $55 DI0 10,40 <br /> � BS5-bl5 �I oo r <br /> I C6 <br /> �(,�5—D�• 130 <br /> W5"�IV• � �r1 <br /> , <br /> a 2 r , <br /> 3 ga.5C) <br /> RELINQUISHED BY SIGN DATEITIME RECEIVED BY (SIGN) DATE[TIME REC 1 ED FOR LABORATORY <br /> a Y l• �'�� �J BY(SIGN ATEITIMELO <br /> + R CEIVED <br /> COLD AND INTACT OTHER PRESERVATIVE OYES NO <br /> ❑OTHER /\ <br /> TURN AROUND TIME <br /> SHIPPED V bFED X ❑UPS CJOTHER SHIPPINCWER NO ❑24 Hr 02 Day �5Day <br /> —910 Day <br />