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ASSOCIATED LABORAT000 <br /> 806 North Batavia • Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 Fax (714) 538-1209 <br /> Company / �( I Phon 5_6? 7 A L Jab No 1 1 t Page of <br /> Prosect Manager Fax 't3Requested�.�"" �t� <br /> Analysis nested Test InstrucLons$Comments <br /> SiName <br /> SiteN J � J 1 roti t# .. �, <br /> Name tl 04 r r [1 <br /> and N <br /> Address <br /> X77?t C44—. �z- <br /> Container -�p <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres "s <br /> / ( <br /> 3 crlFl 6 Ld f' 2�} `ra <br /> WOO OO f-�L.0 )-6004"t i4oars- �r <br /> 5 <br /> r <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished 1 Relmq shgd byz Relinquished by 3 <br /> Sampler t f ! ( <br /> Total Number of Containers Properly Cooled Y/N/NA Signatur Signature r 3 sr Signature <br /> Custody Seats Y/N/NA Samples Intact Y/N/NA Printed Name Printed Name Printed Name <br /> P_,%,"q30e tr$t,,- <br /> Received in Good Condition Y/N Samples Accepted Y I N Dat o?w? 7 U Time �7,I Date Time Date Time <br /> Turn Around Time Rece` ed Byh Rec a By ceived By 3 <br /> Signature UI it�� Sig a / Signature <br /> ❑ Normal ❑ Rush ❑Same Day D dJ8 hrs Printed Name On ed e Printed Name <br /> D 24 hrs 72 hrs <br /> Date Time 61C ime Dae Ti e <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />