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. ASSOCIATED LABORATORIES <br /> 0806 North Batarvia ■ Orcinye CA 92868LAk <br /> Chain of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1209 <br /> Company /7/)2 <br /> I`f)2 �f 0/ L— ('(3 Phon 56 QZ{0 A l. .fob No Page of <br /> Protect Manager U r Fax <br /> !c / e�U� l Analysis Requested Test Instructions & Comments <br /> Protect Name f r S Protect M /c r Site 0 <br /> Name <br /> and rf <br /> Address 6"7-DC,12-M�Y �C4�4—C- [�1TJ 2-0 7�—� t o F c) ,ft©o-5 cf <br /> Sample ID Lab ID Date Time Matrix Container Number/Size Pres Y .� <br /> w-3 a1 20 Oz f%roto 14,0 'lv04 1-Fu, <br /> 3 1 ' F \ x � <br /> X XXPA P-t�TTft� z�ZG� <br /> 11-Aw-y X3= 5 X >C/K <br /> W,10 4 av r TNi�Nc� <br /> X 0 - <br /> sBW-P le uo zvoA 14c-G. X X NOL- <br /> 12 r7 p r SPF <br /> 13 <br /> 14 <br /> 15 �f <br /> Sample Receipt-To Be Filled By Laboratory Relinquished bye 1 Relinquished b2 Relinquished by 3 <br /> Sam ler 3F Z � '� <br /> Total Number of Containers 2( Properly Cooled Y I N/NA CS Signatur Signature Signature <br /> Custody Seals Y/N/NA �p Samples Intact Y/N/NA qeyPnnt N�1 14V` Printed Name Printed Name <br /> Received in Good Condition Y/N �� Samples Accepted Y 1 N CS Date, 2 <br /> .0. 0 LTime •�� � Date Time Date Time <br /> Received By f 1 Received e3 B Race By <br /> Turn Around Time <br /> Signature Signature Signature <br /> J'Norrnal Ru$h Q Same Day El 48 hrs Printed Name Panted Name },e Panted Name <br /> ❑24 hrs D 72 hrs 1(,. <br /> Date Time Date `` ` L,t r0� Time 1 Time <br /> Distribution Wfute Laboratory Canary Laboratory Pink Prolact/Account Manager Goldenrod Sampler/Originator <br />