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CDFW <br /> (Rev. 05.2013) LABORATORY CHAIN-OF-CUSTODY FORM <br /> SECTION 3 <br /> Chain of Custody: Persons relinquishing and receiving evidence: Provide signature, organization and <br /> date/time to document evidence transfers. Start with Box Number 1 below <br /> Relinquished B Submitter Or anization Date/Time Received by 0r anization Date/Time <br /> Print Nam l } Print Name: <br /> ,e��� NVI l� CDFW `L� t` ll ] � �1 �Dk <br /> Sign Name: } �5 Sign Name: <br /> Relinquish d B (Submitter) Organization Date/Time Received by Or anization Date/Time <br /> Print Name: Print Name: <br /> 010- Z�, ��� �I(Lf{ct t <br /> Sign Name: Sign Name: �1 �.+y <br /> Relinquish d B Submitter Organization Date/Time Received by Organization Date/Time <br /> Print Name: Print Name: <br /> Sign Name: Sign Name: <br /> SECTION 4 <br /> Laboratory Description of Sample Upon Receipt: Include the number of containers, identification number(s) and a physical <br /> description of each item submitted for testing. <br /> El <br /> ❑ <br /> �. APPROPRrnTn <br /> ❑ - <br /> - L, ## r 73 <br /> Signature: Date: <br /> 2 of 2 <br /> Page 8 of 9 <br />