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..� ttttttt� 1111111/ �. "IASSMIATM L=7RMbRM <br /> ZI /_ 806 Norfh Batavia 6 Orange CA 92868 <br /> Chain of Custody Record b{D Phone (714) 771-6900 Fox (714) 538-1209 <br /> Company 77 Phone <br /> r40 .tel Q/ (' -56 e21—,3 5�•l A L Job No Page of T <br /> Protect Manager Fax 6�- 2!- � <br /> Analysis Requested rest Instructions&Comments <br /> 5 � �3 <br />� Protect Name �� f� ^ ProteaIf <br /> Site Name <br /> and <br /> Address <br /> Sample ID Lab ID Date Time Matrix Container Pres 't- ki * Q <br /> !Number/Size � - C co <br /> �,o <br /> 2 vv� �3; 3v0 ?� <br /> v "A 13 30 I -00 140dr7- X <br /> 4 I!�� kd 14 VOA- CTC i— X <br /> MW— t Jv \104 (4-U,A Z Z\ <br /> X <br /> 9 <br /> 10 <br /> 1i <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by 1 Relingn e:M 2 Relinquished by 3 <br /> Sampler <br /> r <br /> Total NumbSignatu <br /> Number of Containers Properly Cool N/NA �^ Signature� 0 v W rGTI,� Signature <br /> Custody Seals Y J N/NA Samples Iniac Y/N/NA Printed Name Printed Name Printed Name <br /> &h1'0$tom eL, <br /> Received in Good Condition Y/N Samples Accept d Y/N Dat O,)7 Time Date Time Date Time <br /> Turn Around Time Received Byt^ i Received By 2 Received By 3 <br /> Signature Signature Signature <br /> 0V(r-?w 1C,- <br /> Normal ❑ Rush ❑Same Day ©48 hrs Printed Name Printed Name _ J Printed Name <br /> Ll 24 hrs El 72 hrs Q'll�/� <br /> Date Time Date Time Lt" <br /> Time ZO <br /> ,yam <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator /L <br />