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"MSSMIAM L"09"a lo � <br /> 806 North Bcrtmna ■ Orange, CA 92868 <br /> Chain o Custody Record 12—199 I Phone (714) 771-6900 Fax (714) 538-1209 <br /> Company[17�1� D/ L 4—. Phon 5'62 12, r 364? <br /> A L Job No Page of <br /> Protect Manager Fax <br /> SY 121— �3' Analysis Requested Test Instructions &Comments <br /> Protect Name Protect <br /> Site Name t <br /> and <br /> Art- <br /> Address <br /> Sample 1D Lab ED Date Time Matrix Container Number/Size Pres �1 <br /> t i H F w F v-` 12- --o'7 JJ'-0Q I'V12- )T IJ�A SZ N D l4 E ;K x <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt -To Be Filled By Laboratory Relinquished by ti 1 Relinqu d h�y�L' Relinquished by 3 <br /> Sampler l'F <br /> Total Number of Container$ l Properly Cooled Y/ NA Signator Signature 0 Signature <br /> t7 V F�%1�^}4-w <br /> Custody Seats Y/N/NA Samples Intac Y 1)N/NA Printed Name Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accepta( /N Date 1-1vim Time Date Time Date Time <br /> 6- t� <br /> Turn Around Time Recety d By 1 Received By 2 Received By 3 <br /> n�lr444 <br /> Signature Signature Signature <br /> l�Normaf ❑ Rush USame Day ©48 hrsL)24 firs CI 72 hrs <br /> 1)-V�� <br /> Printed Name Printed Name Printed Name <br /> G�tI <br /> Date Time Date 11-0Time Date Time <br /> � <br /> Distribution White Laboratory Canary Laboratory Pink Prolecl/Account Manager Goldenrod Sampler/Originator <br />