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ASSOCIATED LABORATORIES <br /> 806 North Batavlar + Orange CA 92868 m\ <br /> Chain of Custody Record Phone (714) 771-6900 Fax (7I4) 538-1209 <br /> Company ''' /�, 011— g Phon 61-6 <br /> � <br /> 72 q2, -3��� A L Job No Page of <br /> Protect Manager �-xJ Faxt� a f1 l�U S tJf`•!/G� 5`6 Z �2(�-�j.Gt� Analysis Requested Test Instructions&Comments <br /> Protect Namef �. n Protect N <br /> Site Name L 1 r o J { <br /> and �� 'Wrr 0 H W� ']Y I r� <br /> Address ^��C �r�F J 21!5_ �( Z ©T T Q 4 4. <br /> Sample ID Lab ID Date Time Matrix Container Pres 0. I <br /> Number/Size co Sc <br /> z T-6 -,( mz- J1-04 I5'�o 14 n 4 -VO4 X X k <br /> his _i o 01 k F-0P_ mK Ga�rl�}l <br /> 3 M LV_ C 15'>j 4 k x cokpooAUSS r l� <br /> 6 Mw- 2. 0 «F� x <br /> Mw 3R* 16:7o <br /> e ,.% - <br /> ,a <br /> (Pap Evw15:So Z-VD0 c F <br /> 11 <br /> 12 Al i <br /> C. <br /> 13 <br /> 14 <br /> t -Me <br /> 15 <br /> Sample Receipt-To Be piled By Laboratory Relinquished b 1 Relin ish��by� t � �2 Relinquished by 3 <br /> Sampler <br /> Total Number of Containers Properly Cooled Y/N/NA SignSignature `f vSignature <br /> Custody Seats Y/N/NA Samples Intact Y/N/NA Pn \N'4 e�p"CLj Panted Name r'F j Panted Name <br /> Received In Good Condition Y/N Samples Accepted Y/N Date �I Z (7 Time , Date I D to Time <br /> Turn Around Time Received 9 1 Rede d z ecelve 3 <br /> Signature Sig ure Signature <br /> Normal Ll Rush ©Same Day Ll 48 hrs Pnnted Name Pnnt a Panted Name <br /> D 24 hrs ❑72 hrs <br /> Date Time Date me <br /> +� � ! D�e—��(� Time <br /> Oisbibutlon Zito-Laboratory Canary-Laboratory Pink Project/Account Manager Goldenrod-Sampler/Oris <br />