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Apollo lytics, Inc. <br /> 2960 Airwa ve.,Suite B-101 •Costa Mesa, CA 92626 Chain olku s t o d • <br /> Phone(714)751-3210•FAX(714)751-6414 DATE/ 1`L PAGE OFL--. <br /> PROJECT MANAGER: �_0 Its Recommended Quantitv and Preservative Provide tri le volume on 6C Samples) <br /> Cb <br /> COMPANY: �� I UL U-6:CK A�SSUC l CD 0 0 0 e <br /> ADDRESS: = o o CM <br /> J J J J <br /> cm <br /> CD CD <br /> O O <br /> = v = _ = o 0 o E o - o E E <br /> PHONE# I —GI I (o 7 - l SS FAX# �l ► S 3 �2Z`3 0 N N N c c v o c `r' o 0 <br /> J J J J J O O O O X X X O X O O V <br /> V 'R T Q• C N N N Uf N In U') <br /> BILL T0: r1� I L.( r `�< I°CS C t tCi�S <br /> COMPANY: <br /> El j 5 S 61 L i C4A L N o o C\js C5 Lo <br /> ADDRESS: 00 C\j <br /> \ L 00 o co n 00 ° 3y <br /> cl� 0 c C/) C7 tO N S <br /> `U Q <br /> c Z <br /> v a Co E S E n; — <br /> / �j �j n G/) v G7 H OJ pOp W a o` N U M a Fp w <br /> N h w (/� Q CL <br /> Cz <br /> p m N 2 a) io N Rf N O (-/ o <br /> SAMPL : (Signatur PHONE NUMBER U U U X U E m - = cc _ U J U w J <br /> x m C, C7 �— U y 2 -o c c oo 2 y o .D v m T 1 <br /> 0 0 m O otf o c a> O w tO 'c — ' � = E <br /> ¢ o` _ <br /> SAMPLE ID DATE TIME MATRIX LAB ID O 5 z °' o a '— O X o 0 o E n a E Z <br /> > _ r- cn 0- o Co a Co � m f ¢ O > cn w 0 � a `� z a <br /> rx <br /> Z <br /> s W I - r✓. C12 -f -a), ZZ) yr <br /> x Z <br /> �- Q <br /> O <br /> J <br /> J <br /> O <br /> a <br /> i <br /> m <br /> c <br /> m <br /> U <br /> Z <br /> O <br /> PROJECT INFORMATION SAMPLE RECEIPT RELINQUISHED BY: 1. RELINQUISHED BY: 2. RELINQUISHED BY: 3. <br /> PROJECT NUMBER: 016 TOTAL NUMBER OF CONTAINERS S.Si ure:- me: Signature: Time: Signature: Time: <br /> PROJECT NAME: u Z n//4 LAS CHAIN OF CUSTODY SEALS Y/N/NA o <br /> PURCHASE ORDER NUMBER: INTACT? Y/N/NA P inted Na at : Printed Name: Date: Printed Name: Date: <br /> lS i i <br /> SHIPPED VIA: — RECEIVED GOOD COND./COLD CQr�pany: Ste, Company: Company: <br /> TAT: ❑24HR ❑48HR ❑1WK WKS AAI RFS#: Q4 © a"/ <br /> Comments: <br /> RECEIVED BY: 1. RECEIVED BY: 2. RECEIVED BY: 3. <br /> I <br /> re' Time: Signature: Time: Signature: Time: <br /> Name: / E 9 Printed Name: Date: Printed Name: Date: <br /> SAMPLE DISPOSAL INSTRUCTIONSTWes / <br /> ❑AAI Disposal (By Quote) ❑ Return ny Company: Apollo Analytics,Inc. <br /> ❑ Pickup (will call) �(i.�1,L "cS <br />