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ASSOCIATED LABORATORIES <br /> 806 North Batavia a orange, CA 92868 <br /> A\ <br /> Chain of Custody Record Phone (714) 77I-6900 a Fax (7I4) 538-1209 <br /> -� Phon �.� 1 �J F�'$j! A L Job No J `t `t a U Page of <br /> Company(/fP-11 1'"{ <br /> Protect Manager Fax !�s Z r- 0 Analysis Requested Test Instructions&Comments <br /> t�Md- <br /> Protect Name Prolec # <br /> rd <br /> Site Name <br /> and <br /> Address f CAA S JVIK <br /> Sample ID •Lab ID - Date Time Matrix eontainer Pres <br /> mber/Size <br /> o u.l-t -� ,� - -off 3'�o t o - L 1�1z� <br /> 2 �v ^/ �3t�v 3-V op, t+CA, �' ►� , rt�c <br /> 3 �,U�—� Ubly —foo lav <br /> 5 ? r—L ;5 k—Volk W-CIL_ <br /> 6 �W. k—Vot l+C L, X <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Relinquished by 1 Relinquished by 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory Sam ler .M. <br /> . `STIM <br /> signal Signature <br /> 0V W7(�a� Signature <br /> Total Number of Containers t Properly Coo Y/N/NA r"yK i+ <br /> Printed Name Pnnted Name Printed Name <br /> Custody Seals Y/N/NA Samples Int Y N/NA <br /> Date q yy�� n 0 Time T Dat <br /> Samples Acce1e Time Date Time <br /> Received in Good Condition Y/N P P N — '1-0'l } �f 3 <br /> f �' <br /> Received By 1 Received By 2 Received By <br /> Turn Around Time <br /> W �- <br /> Signature � Signature Signature <br /> �,/NO RtJSft o ITER-N-� <br /> lJ l me Pnnted Name V Printed Name <br /> ❑ 0 24 hrs L)72 hrs❑Same Day ❑48 hrs Printed NaN� <br /> p �TimeDate Time 2,0 Dat es Time OF. <br /> c <br /> —2�v <br />