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ASSOCIATED LABORATORIES <br /> 806 North Batavia • Orange CA 92868 <br /> Phone (714) 771-6900 Fox (714) 538 1209 <br /> Chain of Custody Record 12o'533 <br /> FProlect <br /> mpany F'. ' Pho 51,r q2-d�-3'J t � A L Job No Page of <br /> 171 f-r r L G <br /> Manager � � ��� � Fax �6 q2-1�-`f 4uAnalysts RequestedTest Instructions& Comments <br /> lect Name Prol # <br /> Site Name S t .M1� F^L N g� <br /> and `� !Pi C 1— j t it�h /+y W\ <br /> Address `� 7 �j l r vl `�' ' C32 <br /> j Container <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres �_ t Z <br /> _ <br /> 2 V w- q2r�- 13 LQJ 7 <br /> q A- x ` <br /> 5 V W r co`1- <br /> �C <br /> 8 <br /> 9 i <br /> 10 <br /> I <br /> i1 <br /> 12 <br /> 13 <br /> T4 <br /> 15 <br /> Relinquished a 1 Rehegmshed by Relinquished by 3 <br /> TrIA <br /> Sample Receipt-To Be Filled By Laboratory Sam ter W--7 pi-4 ,")t.(��4 <br /> S� natur C Signature 4�c 5tgnature <br /> fty <br /> Total Number of Containers Property Cooled Y/N!NA g j' �. VV <br /> Printed Name Printed Name Printed Name <br /> j CSamples Intact Y I N I NA <br /> Custody Seals Y!N 1 NA 1 f r7 ' <br /> Dat Time Date Time Date Time <br /> Samples Accepted Y I N <br /> Received in Good Condition Y!N P <br /> Received By 1 Recel d Received By 9 <br /> Turn Around TimeGv�s11-� S'+T7�" <br /> Signature d 5ignatur Anature <br /> ❑Same Day ❑48 hrs Printed Name P riled m , V � r Printed Name <br /> Nor { ❑ Rush p 2a hrs ❑72 hrs I ) <br /> Date Time D e Time I V s C�� Date Time <br /> Il Z <br /> d-Sa ler/Qriginater <br /> .e firta �ry �Labor�mk �ccou�pm � � <br />