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• ASSOCIATED LABORATORIES <br /> 806 North Batavia e Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 a Fax (7i4) 538-1209 <br /> Company ! `_ Pip �� [ _ r'`! � ru� <br /> t- J 3�� A L Job No Page of <br /> Protect Manager a Pa n <br /> Analysts Requested Test Instructions &Comments <br /> Protect Name `J �^ r �g Protect# Jam <br /> L t� r � J Lk�i b"C j AZt ( 1 <br /> Site Name <br /> and Z, <br /> Address l_ <br /> a7 0C 71-t- C it <br /> 1 <br /> Sample ID Lab ID Date Time Matrix Container Pres <br /> Number/Size `! t^ <br /> rf <br /> 2 �f F("Lp l�f i. f�! +�� C f ��2+ ��1 h— �� t��1/ ��E✓!`r x, <br /> 3 <br /> y <br /> 4 <br /> � fr <br /> � fr <br /> / ell r <br /> 8 / <br /> �r r <br /> 9 � <br /> 10 <br /> 11 <br /> 12 / s <br /> 13 <br /> 14 <br /> 15 ' <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by , ' 1 Relinquished gy ' 2 Relinquished by 3 <br /> Sampler ` •l�,syl- Y"{ 43tw�- <br /> Total Number of Contamers Properly Cooled Y/N/NA Signature -�T Signature Signature <br /> Custody Seals Y!N/NA Samples Intact Y 1 N/NA a l Printed Name, Printed Name Printed Name <br /> Received in Good Condition Y 1 N ®/ Samples Accepted Y/N Date Time 12-0 01 J y Date Time tate Time <br /> Turn Around Time Received By G 1 Received By 2 Received By 3 <br /> 1. Signature Signature �r4 Signature <br /> Same Day ❑48 hrs <br /> Normal ® F�USFI printed Name Printed Name f Printed Name <br /> ❑24 hrs ❑72 hrs <br /> Date Time Date Time Date Time <br /> Distribution White Laboratory Canary Laboratory Pink Profact/Account Manager Goldenrod Sampler/Originator <br />