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ASSOCIATED LABORATORIES <br /> Chain o C ,�A <br /> ustody Record 806 North Bat=a a Orange CA 92868 <br /> � <br /> Phone (714) 771-6900 a Fax (714) 538-1204 <br /> Company ! <br /> T1,f A I L co 1 C <br /> Project Manager :J A L Job No <br /> Fax t y,, Page of <br /> Project Name � y'�'��+��d Analysis Requested Test Instructions & Comments <br /> Site Name G7�i�� �■ I[l" +� b N <br /> and <br /> Address <br /> P Q <br /> � ,1 p Sample ID Lab ID Date Time Matrix Container Pres lrJ <br /> Number/Size x <br /> " 7 —t60 MIP, 14096 x ?C <br /> 10r40 <br /> 3 <br /> a <br /> S <br /> 6 <br /> 7 <br />� 8 I <br /> B <br /> 10 <br /> It <br /> 12 <br /> 14 <br /> 1S <br /> Sample Receipt -To Be Filled By Laboratory Relinquished <br /> Sam ler bye!,, Rehngj��%_,t4.�2 Retmqulshed by 3 <br /> Total Number of Containers ZProperty Cooled Y/N/NA Sjgnatur Slgnalure Signature <br /> Custody Seats Y/N/NA Samples Intact Y/N/NAj4e- <br /> � Printed Name Printed Name Panted Name <br /> 75e <br /> Received In Good Condition Y!N Samples Accepted Y/N Date l n Time ,a Date Time Time <br /> r)L.0� '�tl Date <br /> Turn Around Time Rece+vel gv � Recetwed a Received By 3 <br /> Signature Signature Signature <br /> Normal RUSK ❑Same Day ❑48 hrs Panted Name <br /> Printed Name Printed Name <br /> ❑24 hrs D 72 hrs <br /> Date Tama Date Time Date Time <br /> t 2 t3�z lS <br /> Distribution White laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/originator <br />