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ASSOCIATED LABORATORI <br /> 806 North Batavia ■ Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1209 <br /> CompanyffT)e6f ✓ 1 fs'�`ir P �.G �`L��� A L Job No G s� Page of <br /> Project Manager F �j y Analysis Requested Test Instructions &Comments <br /> Project Name <br /> aSite nd Name 4 I Plf `N r—,,c— 4W:- T�v1�j <br /> Address � `J� Cry 6524– -) iG <br /> Sample ID Lab ID Date Time. Matrix Container)-) <br /> ontainer PCes <br /> Number/Size <br /> a <br /> 5 <br /> ro <br /> 7 <br /> 8 <br /> 9 <br /> 101 <br /> 11 <br /> 12 <br /> 13 <br /> 1a <br /> 15 <br /> Sample Receipt -To Be Filled By Laboratory Relinquished by 1 Relinquished 2 Relinquished by 3 <br /> Sampler h F <br /> Total Number of Containers Properly Cooled Y/N/NA Signature Signature Signature <br /> Custody Seals Y 1 N I NA Samples Intact Y/N I NA Printed Name Printed Name Printed Name <br /> e <br /> Received <br /> Time Date Time Date Time <br /> ed in Good Condition Y/N Samples Accepted Y 1 N <br /> Turn Around Time <br /> Received By,n r`� 1 Received By 2 Received 9y 3 <br /> Signature (' CSignature ' 1 Signature <br /> ❑ Normal RUSK ❑Same Day LI 48 hrs Printed Name Printed NamiU Printed Name <br /> 24 hrs2 hrtiV vu} <br /> s ��}} <br /> Date Time Date Time Date Time <br /> G <br /> .r <br /> Distribution White Laboratory Canary Laboratory Pink Pronect/Account Manaqer Goldenrod Sampler/Originator <br />