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ASSOCIATED LABORATORIES LJ <br /> Chain of Custody Record Bab North Batavia a Orange CA 92868 <br /> L j Phone (714) 771-6900 Fax (714) 538-1209 <br /> Company Phone <br /> �� �+ 2�`3 5�'s A L Job No <br /> Proleci Manager Fax f Page ofr� <br /> Prosect Name q, 1� �� � Proect �d Analysis Requested Test Instructions &Comments <br /> !-rL�f T17 L /17 P,— I ,� Z <br /> Site Name y <br /> and <br /> Address `a <br /> F,9 ce7 <br /> Sample 1D Lab 1D Date Time Matrix Container rl <br /> Number/Size Pres q, <br /> T <br /> 0 <br /> 3 I +�L!✓�.,cth'� ��—z���� ,/0 20 rf e2 th-i2 X �C <br /> a <br /> 5 <br /> 6 <br /> 7 <br /> 418 <br /> ti- <br /> 10 <br /> i1 <br /> 12 <br /> 13 <br /> T4 <br /> 15 <br /> Sample Receipt- To Be Filled By Laboratory Relinquished y 1 Relinquished by 2 Relinquished by 3 <br /> t <br /> Sampler rvf,,)r <br /> Total Number of Containers Properly Cooled Y/N/ A Signal SignatureSignature <br /> n <br /> t9 V,!-"aA i C1- <br /> Custody Seals Y/N/NA Samples Intae!"Y—/N/NA Print f � Printed Name Printed Name <br /> Received to Good Condition Y/N Samples Accept /N Daae _ Time ry Date Time Date Time <br /> Turn Around Time Receiv�edu'a8y� �1'r�b� 1 Received By 2 Received By 3 <br /> G <br /> E. ❑Same Da <br /> Signature 0 V�"/214 f cma Signature Skgnateue <br /> Normal ❑ Rush y U 72 hrs Printed Name Printed Name Printed Name <br /> ❑24 his D 72 his „1 <br /> Da Time Date Time Date Time <br /> Oistnaut,on Laboratory Ca Labift Pmk VAcc ria er nrod JWOngMr <br />