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ASSOCIATED LABORATORIES* <br /> 806 North Batavia ■ Orange, CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 Fax (714) 538-1209 <br /> LM\- <br /> Company �)� ��, C. �( � :7.7 A l Job No � <br /> I Page of <br /> Project Manager Fa �- Analysis Requested Test Instructions&Comments <br /> Project Name �' � � �� Project <br /> Site Name / .{ <br /> and <br /> Address ! <br /> 1, <br /> Sample ID Lab ID Date Time Matrix Container Pres <br /> Number/Size <br /> 2 ffr 4 x <br /> 4 <br /> it-1 2. 1o,2.o <br /> 5 <br /> I s <br /> r9 <br /> 10 <br /> 11 <br /> 12 <br />� 13 <br /> 14 <br /> 15 <br /> Relinquished by 1 Relinquished by 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory <br /> Sampler <br /> Total Number of Containers Properly Coote /N/NA Signature r Signature Signature <br /> Custody Seals Y/N I A Samples Intact I N/NA Printed Name Panted Name Panted Name <br /> =' <br /> Received in Good Con1 Ion /N Samples Accepte Y N Date06 <br /> Time !� -`_ Date Time Date Time <br /> Turn Around Time Received 1 C Rec`od By 2 Received By 3 <br /> � �// Signatu Signature Signature <br /> LD Normal ❑ Rush ❑Same Day 48 hrs Printed Name Printed Name Printed Name <br /> 0 24 hrs ❑72 hrs <br /> Date Time a Time Date Time <br /> )1 ,-1 U1 10 4,L) <br /> -Distribution White Laboratory Canary Laboratory Pink-Project/Account Manager Goldenrod Sampler/Originator <br />