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ASSOCIATED LABOPATOR140 <br /> 806 North Batavia • Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 1, Fax (714) 538-1209 v <br /> Company T7 p f5,p.,ta Q)1 � � C/� ` Pho � �3 � 0 7 <br /> J t Tfc.` %2 j "'��j A L Job No Page of <br /> Project Manager <br /> � a Fax { �(` Analysis Requested Test Instructions & Comments <br /> Project Name <br /> Project k I <br /> Site NameX�f V 2 µ <br /> and <br /> Address ki <br /> -l�C � <br /> STb C,e TVl� <br /> Sample ID Lab ID Date Time Matrix Container Pres <br /> Number/Size <br /> V W7CCVt 1' t <br /> i V Lv r -c - <br /> 9 <br /> 10 <br /> 11 �� <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinqu shed b 1 Relm fished Relinquished by 3 <br /> Sampler rel <br /> Total Number of Containers Properly Cooled Y/N NA Signa i Signature Signature <br /> Custody Seats Y 1 N NA Samples IntacY/ /NA Pnnte�NamV � Panted Name Panted Name <br /> Received to Good Conditi n Y N Samples Accept Y/N Qate }�y�� Time I Date Time Date Time <br /> Turn Around Time Rete d By r Received By 2 Received By 3 <br /> S+gnatu l J Signature Signature <br /> L4)Normal ❑ Rush ❑Same Day ©48 hrs Panteda Printed Name Printed Name <br /> ❑24 hrs ❑72 hrs <br /> Dfl ` Time Date Time Date Time <br /> 3 <br /> Distribution White laboratory Canary Laboratory Pink Prolect/Account Manager Goldenrod Sampler/Ortainator <br />