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�,�,, a R - ,r\ ► t,c c� ASSOCIATED LABORATORIES <br /> 806 North Bataxvda ■ Orange. CA 92888 LA <br /> Chain of Custody Record Phone: (714) 771-6900 ■ Fant: (714)538-1209- <br /> G°t"par",,tl-,r`:4 oa`� Co, Phone CSI;2)4z-+-3s <br /> A.L.Job Na. Z � � page A—of 4 <br /> Pm;ecl Manager Fax <br /> CSVZ1 Z1-?Sti Analysis Requested Test Instructions&Comments <br /> Prnjeci Name Project 4 <br /> Site Name <br /> and 'r'C L: I-L"L '24477 �J k�fkc.s �`Z: �2. <br /> S�c�'�..] C-+t>• � � N <br /> ress <br /> ContEfiner <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres. <br /> 3 U <br /> a <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 1D <br /> 1t <br /> 12 <br /> 13 <br /> 14 <br /> 16 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by 1. Relinquished by 2. Relinquished by 3 <br /> Sa r. <br /> Total Number o4 Containers Properly Cooled Y/N/NA Spiig�raatture: ` Signature: Signature: <br /> Custody Seats Y/N/NA Samples Intact Y/N/NA Nam Printed Name. Printed Name' <br /> Received in Good Condition Y/N Sampfes Accepted Y/N Date: Oats Time; [late: Time; <br /> Turn Around Time a By: 0, 1. Received By: 2. Received By: 3. <br /> t r Signature: Signature; <br /> ® Normal D Rush D Same bay 0 48 hrs. Wrinfed Nanw; Printed Name: Printed Name: <br /> ❑24 hrs. ❑72 hrs. <br /> Da . Time: Date: Time: [Yate: Time: <br /> Distribution: White-Laboratory Canary-Laboratory Pink-PrvJeCt/ACeount MareW <br />