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CHAIN OF CUSTODY RECORD Pg__L of -� <br /> ® FOR LABORATORY USE ONLY <br /> Method of Transport Sample Condition Upon Receipt <br /> I ® Advanced Technology Client ❑ <br /> 1 CHILLED ,J Y❑ NO 4 SEALED Y ❑ NO <br /> ® Lahoratone5 P O# ATL ❑ �,� <br /> 3275 Walnut Avenue <br /> (562) <br /> OverN ❑ 2 HEADSPACE(VOA) YQfN❑ 5 #OF SPLS MATCH COC Y O N 0 <br /> Signal Hill,CA 90755 Logged By_ L� _ Date <br /> Sign)489-4045 • FaX (Sb2)989-4040 Other 3 CONTAINERINTACT YPr 'N❑ 6 PRESERVED Y D,N ❑ <br /> Client C—r0 tO Address ul g?6 1 f �!� TEL { Z� ) � 7��✓ <br /> Attn f r IV j (' ��{ t�} r City .j J G 12-IM0 9_r' State Zip Code q-tt�e,& FAX( ) <br /> Project Name r� Project Sampler Pri led Name) (Signature) R <br /> 1 P_NNVk11i # ' (ri� � -��� pZ�2Z� �+1r� v� i` �_`. -:5 <br /> Relinquished <br /> Relinquished by (signatme and Pnnied Name) �. Date 10-15 Oil Time Received by (signature and Printed Name) _ Date ! ` Time <br /> Relinquished by (Signature and Pnmed Namol Date Time Received by (signature and Pnnted Name) Date Time <br /> Relinquished by (Signature and Pnnted Name) Date Time Received by (signature and Pnnted Name) Date Time <br /> I hereby authorize ATL to perform the work Send Report ToBill To Special Instructions/Comments <br /> indicated below Ann I r r t ( W tom' Attn ` -12-('-U "�—C)05 Vex, 1 •Z l <br /> Project Mgr/SubmitterCo 9� �i ,J Co t�f 0 U� t (4 D5 C� � <br /> Print Name DateAddress 016 QAddress <br /> Siqnaiure city State Zip City State Zip <br /> Sam /R <br /> pleecords-Archival 8Disposal Circle or Add SPECIFY APPROPRIATE QA/ QC <br /> Unless otherwise requested by client,all samples will be disposed 45 days after Analysis(es) MATRIX Z RTNE <br /> receipt and records will be disposed 1 year after submittal of final report Requested 0 CT ❑ <br /> Storage Fees(applies when storage is requested) < <br /> •Sample $2 001 sample 1 mo(after 45 days) SWRCB ❑ <br /> •Records $1 00/ATL workorder 1 mo(after 1 year) Amy `v �' 1 �� container(s) w Logcode <br /> I 03 <br /> LAB USE ONLY o`` m� aro o ¢° ¢° ° ( ) OTHER <br /> T Batch# Sample Description g e CO- �, o �Q J2 w <br /> o� p� ¢� TAT # Type 0- <br /> REMARKS <br /> Lab No Sample I D 1 Location Date Ttme �� $�" mti� �ry �o �o s� c, a' <br /> 071 7�- m 0 LN - <br /> �1' 4� - <br /> > � �� <br /> > ' <br /> v 0 , <br /> •TAT starts B Ilawrng da if �TAT p. Overnight B Emergency C- Critical D= Urgent B_ Routine Preservatives SD. C-4 C <br /> Y1<-24hr Next workda 2 da s — 3 Workda s —7 Workdays] H=Hcl N=HNDa — <br /> samples rec ter 3 p m <br /> ntainer Types T=Tube V=VOA L=Liter P=P[ =Jar B=Tedlar r G=Glass P=Plastic M=Metal Z=Zn(AG)� O=N T=NazSz03 <br /> J!,- -r i <br />