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ASSOCIATED LABORATORIES <br /> 806 North Batavia ■ Orcmge, CA 92868 <br /> Chain of Custody Record Phone (7I4) 771-6900 Fax (714) 538-1209 <br /> ,, r q 11 � L 0 i/ <br /> Company # ¢ � d r Phone c � �2a Jo,/ A L Job No 1[ Page of <br /> Protect Manager � � f �s M Fax L6 7q g j : `fes Analysis Requested Test Instructions&Comments <br /> Protect Name ri J / r ��( Protect <Z <br /> ��y i <br /> and Site Name f�y ��! —1 LSC (�w -, tit,: <br /> Address <br /> Sample ID Lab ID Date Time Matrix Container Pres �- CD X <br /> Number/Size <br /> 2 1"t4 pwt'El< 0q /1 00, 4C It'] Trio tl�p- aC) i Z }G <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 9 <br /> 10 <br /> 31 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Rellnqurshe��*� 1 Rehn�u�sha�LW g4 2 Relinquished by 3 <br /> Sam ler Cj-r� <br /> Total Number of Containers Property Cooled Y/N I NA Signal Signature ��earaw Signature <br /> CustodySeals Y I N/NA Samples Intact Y I N I NA Printed Name r Primed Name Printed Name <br /> p '�P�-� <br /> Received in Good Condition Y/N Samples Accepted Y IN Dat �f�J Time rt t rZ Dale Tim Date Time <br /> Turn Around Time Re''--a' llgtye_d,By _ celved By 2 Received By 3 <br /> Signature P � 1 ature <br /> &'-N10 rmaI ❑ Rush 0 Same Day ❑48 hrs -Printed Name 11 P led N e Printed Name <br /> ❑24 hrs ❑72 hrs i <br /> Date Time As D41 7 Time t Date <br /> o <br /> Distrjbution While oratory Canary Laboratory Pink Protecl/Account Manager Goldenrod Sampler/Qnginator <br />