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i <br /> 0 ) ADDlied P & Ch Laboratory ' <br /> Cham of Custody <br /> A C, j, 13760 Magnolia Ave. Chino CA 91710 <br /> Tel: (909) 590-1828 Fax: (909) 590-1498 Please Print in pen Page _L_ of <br /> Clic„t: � 1, Contact: <br /> i1V 't e<i yi?G � [ I Tel # : (� 98 Fax <br /> Addre s: 4C�ity: �rlr �. 1 State: Zip code: V Z. q <br /> Bill tu:� 'r 350 !QL - I�Vtr' C Analysis Items <br /> Project Sante/Code lob # P.O. # white - W:t:, report <br /> Project Address APCL Quotation # -� Yellow - Uat copy- <br /> Due Date: regular ❑rush: —days — hours Sampled by: rd <br /> 1 Pink - Originator <br /> �F'it.ld Sarnple Sample Date Time Sample Preser- # of <br /> lD tio. Description Collected Matrix vation Containers I Remarks <br /> _VL <br /> -AW-3 jLk <br /> l ,J o 4 k <br /> I <br /> �� -� i L'•>� T t'.- t � it l � � � <br /> er [4 t l t t j i <br /> X1-1 LJ <br /> QC Requirement �egalar, ❑QA/QC Report; ❑WIP; ❑Raw Data, []Extended Raw Data []CLP; []ACE ❑AFCEE ❑NEESA_(E,C or D); []Other—(Please specify) <br /> sposal by APCL ❑bold for days after receiving date If not specified,samples will be discarded 45 days after samples are received. <br /> Sampir Disposal ❑Return <br /> Sample Condit' ❑Intact; ❑Broken. Cooler Seal: ❑Intact; ❑Broken; E] None . Tag Temperature: ❑ Room El Cold <br /> Reif nyttished � Date/'Time 0:44 Received by Date/TimeC�f e� / 1c� <br /> Relill+llshed by Date/Time / Received by Date/'Time � <br /> APCL USE ONLY Service # Note: <br /> 1111111111hAli <br /> C!u•nts un nd that alt terms described in the proposals, quotations for this project, and/ort eral terms provided in the current APCL price schedules will be followed APCL ' es the right <br /> goo.. i'L or w deli any , if it 's s redo rm5 prod bee n .'w^,T „_' " <br />