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�1S� 17-/= <br /> I� �O�O <br /> 806 North Batavia • Orcmg CA 928b8 <br /> Chain of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1 9 <br /> Company —14 ©t C - Phone6 C f A L Job No Page of <br /> Protect Mana er Fax �C JUQ <br /> g 5 �V aUA' A 6 G�Z�r j�,{,� Analys s Requested Test instructions&Comments <br /> Protect Name y,O`I. w Proles" <br /> Site Name �' ���� +�`Vo <br /> and U4 <br /> Address no <br /> t r1 y T a <br /> 17aCly= <br /> Sample ID Lab ID Date Time Matrix Container Pres 4 <br /> !J �l�('] /� J� Number/Size <br /> 1 4 1/Or� 01, —oA-o"1 ��f.U`• f� �/ 1 x l 0 h4 arG` 7L <br /> 2 V�1,�c� �11W3—VO* I� CL �M� <br /> 3 0-rt � '. d —6-00AIS No X <br /> 4 <br /> i wr. —A k-Volt (4 CL <br /> s fA too—f z 2 :no k —Volk SGV 7� <br /> 7 <br /> a <br /> g <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by ' /��, C : Rehnq� =s 4 Relinquished by 3 <br /> Sampler 1�1 �� <br /> Total Number of Containers Properly Coo YIN/NA Signal r Signature �1 Signature <br /> Custody Seals Y/N/NA Samples Int t Y/N/NA Printed Name Printed Name V 9�7 Printed Name <br /> Received in Good Condition Y/N Samples Accept N Die —01rwf Time , Date Time Date Time <br /> Turn Around Time Recvei.tk}F.4 Received By 2 Received By 3 <br /> �/ Signature V,�r�r E Signature Signature <br /> L/ Normal LI Rush Ll Same Day ❑48 hrs Printed Name I rr Printed Nam6V I Printed Name <br /> ❑24 hrs ©72 hrs <br /> Date Time Date Time yo Z <br /> QTime <br /> 2r f �j� O l <br /> 01stnbutmn White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod SampledOriginator <br />