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ASSOCIATED L"ORATORI <br /> dv , 806 North Batavia ■ Orange, CA92868 <br /> dfilaI�l ro ,Custody Record I Phone (714) 771-6900 Fax (724) 538-1209 <br /> r Company, L C4>—' i Ph et ; 3 At Job No 21 Page of <br /> r rolect Manager &VMo- F 2 f�z1'__�5tD Analysis Requested 'rest Instructions S Comments <br /> Project Name /d'n Z � Prqect# / <br /> r( <br /> Site Name 42- A�� /Pd` A M <br /> j and h' <br /> Address <br /> P � B <br /> - Sdmple iD Lab ID Date Time Matrix Container Pros I i <br /> Number/Size H x <br /> ©2 /0: # M MR Wow <br /> 3 � <br /> 4 � <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> i <br /> 9 <br /> 10 <br /> 11 � <br /> 12 <br /> 13 <br /> , <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by ,� i Relin tsh��5 Relinquished by 3 <br /> Sampler -Sepff?F <br /> Total Number of Containers Properly Cooled Y/N/ A S+gnatu Signature Signature <br /> Custody Seals Y M NA Samples lntac Y /NA Printed Name Printed Name Printed Name <br /> Received in Good Condition iq N Samples Accept 2Y/ <br /> / oat o3 I f.m2 Time 16:00 " Time Dale Time <br /> Turn Around Time Receigad 1w l,,,rbTy] Received By 2 Received By 3 <br /> Signature �9�I11� Signature Signature <br /> C1 Normal ❑ Rush 0 Same Day ❑48 hrs printed Name Printed Named �JJ f v��„ 1�Y A�v] Printed Name <br /> LI 24 hrs Ll 72 hrs (Q <br /> Date Time Dateq t� Time b 5?�.y Date Time <br /> Distribution White Laboratory Canary-Laboratory Pink ProjeWAccount Manager Goldenrod-Sampler/Originator �) <br />