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W �x • ASSOCIATED LABORATORY <br /> f <br /> 0 806 North Batavia it Orange CA 92868 <br /> Chain of Custody Record Phone (7I4) 771-6900 ■ Fax (714) 538-I209 <br /> Companyr14rz F q 0/ L L lr P �t: J A L Job No 5,3641 Page_ 1_ — <br /> —of <br /> Protect Manager Fax - Analysis <br /> r� �tlR i r�USc►M� �,� Z J21- �3�O Requested Test Instructions & Comments,� <br /> Protect Name J <br /> Project a <br /> Site Namef T Y <br /> and 16 4 �L P4d1--/C /�V,&:, <br /> Address J f 0C 4 J,V, ` P <br /> Sample ID Lab ID ^� Date Time Matrix Container Pres <br /> p Number/Size X i <br /> I 1 <br /> M,� <br /> 01 .J4 i 3 �� O 3 V 4t f t-f CL 1�NA fisz� wew,' alp <br /> j <br /> 3 <br /> L' sF- h IN C,4 CrA`1ocr r/6_ <br /> 4 Z V X X Ep# MFTr►�4 Z�v <br /> 5 Mw T >( X r 7WAt�OL <br /> 6 Mw g L F_TwtfHov__ <br /> Jilt >C Ix MT,$C-_ <br /> 9 i9iP �t,I�NK ��:c�o Z VOLA 1C k31` t <br /> 1° kc. 6' F-TAh <br /> ,1 V , <br /> L <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by 1 ReEmquishe�bY � 2 Relinquished by 3 <br /> Sampler F <br /> Total Number of Containers Z 1 Properly Cooled Y/N/NA Signature Signature Signature <br /> Custody Seals Y/N/NA Samples Intact Y/N/NA Printed Nar�tyeM Printed Name Printed Name <br /> Received In Good Condition Y/N 'y Samples Accepted Y/N Dat .� . Q Time Date Time Date Time <br /> Turn Around Time Received By r 1 Received By 2 Received By 3 <br /> Signature Signature Signature <br /> 3I <br /> Normal ❑ Rush ❑Same Day ❑48 firs Printed Name Printed Nay �,v Printed Name <br /> ❑24 hrs 0 72 hrs <br /> Date Time Date Time Date Time <br /> Distribution White-Laboratory Canary Laboratory Pink-Project/Account Manager Goldenrod SamplerlOrigtralor <br />