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ASSOCIATED LABORATORIES <br /> 806 North Batavia • Orange CA 92868 <br /> Chain of Custody Record i23 1 L Phone (714) 771-6900 Q Fcfr (714) 538-1209 AM <br /> Company T �Y%� 7 �j! L UT Phone �7 J� 2.('-���'� <br /> ( f A E Job No Page of <br /> Project Manager /hia, ' 0 Fax 51 LJ It 2 f--r Analysts Requested Test Instructions&Comments <br /> Project Name I Project# <br /> Site Name <br /> and <br /> Address �rn C-424-4;,t4 M' E1 <br /> W Container <br /> Sample ID Lab ID Date Time Matrix Pres <br /> Number/Size -o <br /> DLIV -LLJ f-�v F��� ,t -Tr�h 40 h(Ft <br /> CV t(V <br /> 3 i <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> B <br /> 9 <br /> 1 7Z <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished b 1 Reltnggisfie)i b� f2 Relinquished by 3 <br /> Sampler <br /> ! "�` C �F <br /> Total Number of Containers Properly Cooled Y/N/NA Signa r� 5 gnature c1t ` t Signature <br /> i�f✓-�' a�! CJI�� <br /> Custody Seats Y/N/NA Samples Intact Y/N/NA Pn tried N;A � Printed Name Panted Name <br /> Date t�� Time f y �, Date Time Dale Time <br /> Received in Good Condition Y/N Samples Accepted Y/N ;W—?V-Vv ,C rtro <br /> Turn Around Time RBC81Y B _41 Rec ved r, 2 Received By 9 <br /> ,.�/^ Signature Si nature Signature <br /> J !Normal ❑ Rush Q Same Day ❑48 hrs Printed Name P n N { Printed Name <br /> ©24 hrs ❑72 hrs S <br /> Date Time D to x� Time �d r Date e <br /> Distribution Whiteboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Onginator <br />