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ASSOCIATED LABORATORIS <br /> 0 0 806 North Batavia • Orange CA 9286 <br /> Phone (7I4) 77I-6900 ■ Fay (714) 538-1209 <br /> Chain of Custody Record 12(c,711 41� <br /> Company LAS �� Phone(,- <br /> ,6` ry�� l A L Job No Page of <br /> Protect Manage `–� Fax Test <br /> i <br /> •- 117 C.) Analysis Requested Test Instructions&Comments <br /> Protect Namer�JLY <br /> CIL a� , Pralec is <br /> Site Name Ir� t1 a ' :0– rr '0 <br /> and <br /> Address <br /> i <br /> Container <br /> Sample ID Lab ID Date Time Matrix Pres Number/Size t cx. qy <br /> 1 C12 <br /> t Ui vFii o6-Z% n1i 1n oo (4 0 X- dL 4L5 CvI F>rvr� pArte" r ( <br /> 3 <br /> 4 j T— If 4 - V oA <br /> 5 _ <br /> ' ,r4 W,f- 1-0 14 0 k1 - VOA t L X X <br /> e <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 � <br /> Relinquished by 1 I Relmqutshed b 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory Sampler —Mt IG=vc <br /> Total Number of Containers 1 Properly Cooled Y 1 N/NA SignatG— Signatures� + Signature <br /> Custody Seal Y!N/NA Samples Intact 1 N I NA Panted=a V � Printed Name Panted Name <br /> Received in Good Conddio `Y/N Samples Accept Y/N Time Date Time <br /> Date Time Date <br /> Turn Around Time ReC � �T ti nt y Received By 2 Recetved— 3 <br /> Signature U Signature Signature <br /> "forma! ❑ Rush L)Same Day ❑48 hrs Printed Name Printed NaI Printed Name <br /> ❑24 hrs ❑72 hrs <br /> Date Time Date Time u::�J 412 S-- Date lim��U <br /> Distribution White Laboratory Canary Laboratory Pink Protect/Account Manager Goldenrod Sampler/Originator <br />