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. ASSOCIATED LABORATORIES <br /> 806 North Batavia ■ Orcmge CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 • Fox (714) 538 1204 <br /> Company f r _ Phone; <br /> !, 1 f } ! l _ } _ A L Job No { �� Page of <br /> Protect Manager r j rtL <br /> Fax ] _ ; F, Analysts Requested Test Instructions&Comments <br /> Protect Name - ; Protect M i 6 <br /> Site Name <br /> and <br /> Address <br /> Sample ID Lab ID Date Time Matrix Container <br /> Number/Size Pres , <br /> 2 <br /> a � <br /> 5 <br /> 6 <br /> 7 <br /> 8 � <br /> g <br /> 1D <br /> S1 <br /> 12 <br /> 13 '! <br /> 14 <br /> 15 <br /> f Relinquished by_ � 1 Relinquished by � 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory <br /> Sam ampller '' <br /> r , + <br /> Total Number of Containers Properly Cooled Y!N/ A S+gnatureSignature Signature <br /> Printed Name 3r �r Printed Name Panted Name <br /> Custody Seals Y/N/ A Samples Intac Y N!NA f <br /> ,� r ,. <br /> N Samples Accept Y N Date , t r< Time Date Time Date Time <br /> Received in Good Conditi n � <br /> Received By 1 Received By 2 Received By 3 <br /> Turn Around Time - ,' 1 <br /> Signa Signature Signature <br /> 0Normal ❑ Rush ❑Same Day ❑48 hrs Printed Printed Name Panted Name <br /> ❑24 hrs ❑72 hrs Milo= <br /> D t Tim 1.— Date Time Date Time <br /> Distnbubon Whde Laboratory Canary laboratory Pink ProtecliAccouni Manager Goldenrod Sampler/Originator <br />