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JMJW <br /> 806 North Batcmci ■ Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1209 <br /> Company qI31 <br /> P y / (! oPhan" ,SW 2 3� A L Job No ge of <br /> Protect Manager C� t�e� Fax <br /> � <br /> U evsv jH�- 6 2 Z — •(,p Analysts Requested Test Instructions&Comments <br /> Project Name Project to <br /> /\I 0 MT7-fI- w f}—i r 2- 5 1 Pt <br /> Site Name <br /> and <br /> Address �4� P�1� G 4Y <br /> STt0GV—Mt C4 1S2-04) � � <Z$ <br /> Sample ID Lab ID Date Time Matrix ContaNumber/Size <br /> Pres ¢. <br /> l r�? <br /> T- <br /> 01-68-06- 40,V 0 J-) L- 14 !gof <br /> 3-'V0A 4C ?� <br /> 4 INT - �. ��,�� If -VOA- 14GL <br /> 5 I N L4:E r �,� dp —VOA- 14 ct, ?c IX <br /> s <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> i1 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by JrM 1 Relinquished b 2 Relinquished by 3 <br /> Sampler t f� S T 11 <br /> Total Number of Containers ((C Property Cool Y/N/NASig aur Signature Signature <br /> 3 u &TH <br /> Custody Seals Y!N!NA Samples Inta N/NA Prins�tme V p�p � Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accepte l� Date YLIGL� Time Date Time Date Time <br /> Turn Around Time Received By i Received By 2 Received By 3 <br /> SignatureP Signature Signature <br /> vFL2Nj Oi -} <br /> Normal ❑ Rush Cl Same Day L)72 hrs Printed Name Printed Name Its Printed Name <br /> Cl 24 hrs LJ 72 hrs <br /> Date Time Date F3 Time Date Time <br /> v v <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />