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M M M CPRINW C OFFRMR9M M M M of <br /> FOR LABORATORY USE ONLY <br /> Advanced Technology Method of Transport Sample Condition Upon Receipt <br /> Laboracon o P o Client ❑ f CHILLED [-Y�N❑ 4 SEALED Y ❑ Np- <br /> 14-6 <br /> ATL ❑ <br /> 3275 Walnut Avenue CA OverN ❑ 2 HEADSPACE(VOA) Y❑ N;2"5 I OF SPLS MATCH COC Y 2rN ❑ <br /> Signal Hill, CA 90807 Logged By Date FEDEX ❑ <br /> (562)989-4045 • Fax(562)989-4040 t Other+/ _ 3 CONTAINER INTACT Y�N p 6 PRESERVED Y❑ <br /> Client �C f.� Address Z 3 5 6 �E7 �� lT �- TEL <br /> Attn MkTT � �p City Q1:Q E0-(V%6er State CA Zip Code JJ6 54 1 FAX( ) SIPS <br /> Project NameProject# Sampler (Priv�d Name) (Signature) <br /> 40C4 MkiLV—�T 5%643 -&(o-o , Clk¢ms MtF <br /> Relinquished by (Signature aril Pnrded Name) Date Time �.r Received by(Sgnewrc and Prnded Name)Ono VJfIJ "fV,/ Date W7NJ Time <br /> gnaiule j <br /> Relinquished by tsand Pnrdad Name) Date Time Received by tsgrelum and Prvded Name) Date Time 1 <br /> Relinquished by isrenetumand PnrdedNam) Date Time Received by (sigrWureand PmtedNam) Date Time <br /> I hereby authorize ATL to perform the work Send Report To Bill To Special instructionsrComments <br /> Indicated below �Arrl tI Attn { � a� �f�, ok& .5r "�n <br /> Project Mgr/Submitter Attn L: j j 1 <br /> r-" M��r Co co <br /> Print Name ID818 <br /> Address Address <br /> Si nature I CI State Zip City State Zip <br /> %mi)Ieffieccirds,Archival&Disl2osal Circle or Add SPECIFY APPROPRIATE QA/QC <br /> Unless otherwise requested by client,all samples will be disposed 45 days after Analysis(es) MATRIX Z RTNE ❑ <br /> receipt and records will be disposed t year after submittal of final report Requested O CT ❑ <br /> Storage Fees(applies when storage is requested) <br /> •Sample $2 001 sample/mo(after 45 days) i 2 > SWRGB ❑ <br /> •Records $1 00/ATL workorder/mo(after 1 year) y \�� LL, <br /> Loge <br /> I LAB USE ONLY r a P o� o� Container(s) � <br /> T Batch# Sample Description Qmg o � �r �° ve _� �s' w OTHER <br /> E <br /> M Lab No Sample I D 1 Location Date Time ^p �� �� °� "m "� Q°J �� TAT # T e a REMARKS <br /> � 3 0 3 yp <br /> x x i <br /> I <br /> 1 <br /> I <br /> I <br /> i <br /> I <br /> I <br /> I <br /> I <br /> I <br /> t <br /> • i <br /> I <br /> • TAT starts e a m following day at TAT p- Overnight B Emergency C= Critical Q_ Urgent E- Routine Preservatives <br /> 5 - s 24 hr Next workda 2 Workda s - 3 Workdays 7 Workda s H=Hcl N=HNOa S=H:SO. C=4 C <br /> samples received atter 3 p m <br /> Container Types T=Tube V=VOA L=Liter P=Pint J=Jar B=Tedlar I G=Glass P=Plastic M=Metal Z=Zn(AC)2 O=NaOH T=Na2S203 <br /> DISTRIBUTION White with report Yellow to folder Pink to submitter <br />