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ASSOCIATED LABORATORY <br /> 806 North Batavia a Orcmge, CA 92868 <br /> Chain of Custody Record Phone (7I4) 771-6900 Fax (7I4) 538-1209 <br /> Company <br /> - ,y <br /> Pa Y7-H-j,Et C>I� 4 Ph e�y d I„_�L^p/ A L Job No ,,,fff Pae of <br /> Project Manager Pax ;J� ! ( :Jaf g <br /> (�L! ,�'t�U$7�/�c�— 62 g2.I_'- to Analysts Requested Test Instructions&Comments <br /> Project Name //�!�22y ` Rq� y�+� ,Q Prot # ' sD�MOS' <br /> and Sile Name �`Z t7 �/J �s��C i�`� "� T <br /> y`-l7 <br /> Address C44, <br /> 7 6'1�1) -?- f <br /> P L <br /> Sample ID Lab ID Date Time Matrix Container Pres ,y <br /> Number/Size <br /> z M w �� - �2,. 12,.03 k3'Ota F 0 3\J DA' i+CA, X >C Sze ,P ur dZ�oi3 <br /> M/V — 13.LO K X FOR <br /> 3 M � - ��f2- COI-�PQI};401 VMO <br /> 4 W3 K 7C C 'q <br /> , G�-�4-t d F- <br /> 5 &Ply PlkTI*06 92Cv <br /> -l ic <br /> f3 l L of- 4 q <br /> 2, F�7Y/{-14 cr <br /> 1a 7F-2n P <br /> 11 M-re] <br /> 12 <br /> i <br /> 13 <br /> 14 <br /> I <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquishedpy„�� 1 Rehnq�tghec . y � Relinquished by 3 <br /> Sampler b'Ir`" (fp <br /> Total Number of Containers Properly Cooled Y/N/NA Sign 5lgnature Signature <br /> Custody Seats Y/N/NA Samples intact Y/N/NA Pnnt d Name V Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accepted Y!N Date Time Date Time Date <br /> q P 0� 0 y 1� Time <br /> Turn Around Time Received y Coll,, 2 Received By 3 <br /> 4Date <br /> ignature Signature <br /> �u r <br /> Normal ❑ Rush 0 Same Day ❑72 hrs Printed Name Printed Name <br /> ❑24 hrs D 72 hrs <br /> 15 <br /> Time vo De^��� e, _� Date Time <br /> J <br /> Distribution While Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />