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806 North Batavia • Orange CA 9286 <br /> Chain of Custody Record Phone (714) 771-6900 • Fmc (714) 538-1209 <br /> Company ,r /�Fnv Q C C c3' Pho 6 d z(� `3U-I A L Job No t b `� Page of <br /> Protect Mana�A� ;4 <br /> #_) WJI )- Fax,,, z (z� ,tom Analysis Requested Test Instructions Comments <br /> Protect NamUq WkMj,'. pj ac-- <br /> Site <br /> f� Protect M <br /> e�F <br /> Site Name � � f1��� C P �M t <br /> and <br /> Address Gib C44-7v 14 <br /> _A <br /> Container r' � <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres <br /> ' o- -7:1,r--r' Ot J I-O Z q r k H2-0C 5j00 � 141403 / + <br /> 2 5?10441t dlXC F�f`I03 <br /> 3 3 V�� t4 t✓L <br /> 4 <br /> i <br /> 6 <br /> i T <br /> r- <br />? 8 <br /> 9 <br /> 10 <br /> r <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> pler <br /> Sample Receipt-To Be Filled By Laboratory Im 'gt'Od to -� 1 shed by 2 Relinquished by s <br /> i Signature Signature Signature <br /> Total Number of Containers Property Cool Y IN I NA <br /> Panted Name Panted Name Panted Name <br /> Custody Seals Y! NA Samples rota Y/N/NA �y?r�.u, <br /> Date Time } `1 ' Date Time Date Ti <br /> me <br /> Received in Good Condlt� Y/ Samples Accept Y!N <br /> Recetv`d B `� 1 Received By 2 Received By <br /> Turn Around Time " tt <br /> Signature Signature Signature <br /> d��/ ❑Same Day ❑48 hrs Panted Name Printed Name Printed Name <br /> Normal ❑ Rush ❑24 hrs ❑72 hrs !C� <br /> Date Time Date Time Dat <br /> Distribution White Laboratory Canary Laboratory Pink ProtecVAeeount Manager Goldenrod-Sampler/Originator <br />