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�. Itlllllll� t..l. .� t� tilililil� t� <br /> 806 •OG l.E 1 <br /> North Batavia ■ Orcmge CA 92868 <br /> Chain of Custody Record Phone (714) 77I-6900 Fax (7I4) 538-1209 <br /> Company�yy�^- f r L r�� Pho 5 4 7-1 G�1�,�—31�/ A L Job No q, <br /> Page of <br /> Project Manager h„� J„ A a� Fax �6 �1 � ��c 1� y <br /> ry d'tJ ITZ` �-C Anal sls Requested Test Instructions& Comments <br /> Project Name � /� Proj p <br /> andSite Name 'I-61Y f AOt��c– <br /> Address <br /> 614- C`q _moi D j <br /> J �•t� Container TI <br /> f � B <br /> r Sample ID Lab ID Date Time Matnx Number/Size Pres y <br /> ' v' <br /> © 1.t� � 1� .0 Z, 9 '760 o 5 v oA- l Ic(, x. <br />� <br /> 2 o� L-a ri 2- q Ito 142-0 3 Dorf 0 elJ X ?< <br /> S <br /> 3 04. 1$. 02- q:5b 4Lv 3 O/I t4a, X.X <br /> 4 <br /> 1 5 <br /> 6 <br /> 0 <br />< 7 <br /> g <br /> 1n <br />� 11 <br /> 12 <br /> 13 <br /> r <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by�1 1 Relinquished ��Y)nn— 2 Relinquished by 3 <br /> Sampler krT' <br /> Total Number of Containers Properly Cool Y /NA Signature Signature Signature <br /> Printed Name Printed Name Printed Name <br /> Custody Seals Y I A Samples Int t Y/N NA <br /> Received in Good Condtito Y/ Samples Acc pled Y N Date Time 17, <br /> Date Time Date Time <br /> Turn Around Time Receival S'w 'r� 1 Received By 2 Received By 3 <br /> I Signature Signature Sngnature <br /> 1I <br /> 3Normal LJ Rush 0 Same Day ❑48 hrs Printed Name Printed Name Printed Name <br /> V� <br /> ❑24 hrs ❑72 hrs <br /> Date <br /> Time Date Times C! Date ` T+me J <br /> L V / Zy <br /> Distribution White Laboratory Canary Laboratory Punk Project/Account Manager Goldenrod Sampler/Originator <br />