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ASSOCIATED LABORATORIES A\ <br /> 806 North Bat=a ■ Orange CA 92868 <br /> Phone 7I4 771-6900 e Fax 714 538-1209 <br /> Chain o Custody Record r � r � <br /> CYC�I1 ry' <br /> Company+y/rs, I 0 I C&- Pho gy2 G /, _2J fC✓lJp'f A L Job No ! ` Page of <br /> Project Manager EF Fax 6 ./�n'[�_ <br /> AnalY sis Requested Test instructions & Comments <br /> Project Name Prof <br /> Site Name f ��� l'H M <br /> and T <br /> Address T <br /> � T <br /> Sample ID Lab ID Date Time Matrix Container pros, 8 <br /> _ Number/Size <br /> ' MW,tf,10 Z�, 0Z 10'00n S VoA- t+CL ?C X <br /> 2 M W W- Z� ,Vz 104-10142-0 �V01+ µc-L <br /> 3 <br /> 4 <br /> fi <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 a <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by 1 Relinquished by 2 Relinquished by 3 <br /> Sampler i -bk)c <br /> Total Number of Containers Properly Cooled Y/N/NA Signature(1 ,�_ Signature Signature <br /> Custody Seals Y/N/NA Samples Intact Y/N/NA Printed NammC�QIn Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accepted Y/N Dala� I,�,v1�2 Time 'Q ,�O Date Time Date Time <br /> Turn Around Time <br /> Received By� � 0 1 Racenred By 2 Rec�ed By 3 <br /> �2�� <br /> Signature Signature Signature <br /> O Normal ❑ Rush El Same Day Ll 48 hrs Printed Name Printed ham VJ Printed Name <br /> U 24 hrs ❑72 hrs ONS <br /> Date Time Date Time D�teTi <br /> DistribLQion WWI* Laboratory Canary Laboratory Pink ProtecVAccount Manager GoWanrod-Sampler/originator <br /> j <br />