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11 i <br /> II <br /> P <br /> CHAIN OF CUSTODY RECORD �' <br /> FOR LABORATORY USE ONLY <br /> Advanced Technology Method of Transport Sample Condition Upon Receipt <br /> Laboratanes P o# Walk in El CHILLED , yr1�. Y�N❑ 4 SEALED Y ❑ N <br /> 1 Courier ❑ r <br /> 15I0 E 33rd Street f i ^ 2f UPS ❑ �'rjl, 2 HEADSPACE(VIDA) Y❑ Ne 5 #OF SPLS MATCH COC Y fa'N 11Signal Hill,CA 90807 Logged By <br /> I I _ Date t� r Time�j FED EXP ❑ <br /> (562)989-4045•FAX(562)989-4040, ATL ❑ 3 CONTAINER INTACT YCN❑ 6 PRESERVED Y [INJZ <br /> Client I Address rTEL ( ) <br /> Attn i� City state Zip Code FAX ) <br /> Protect Name Q / Protect#�r�r I, �� -0 Sampler sP def <br /> Relinquished re �'! i D-92!f 1ate d I![Q�� Time Received by ts4i,.wm am Pr.ned r41 �S Q at ��.�� Tame <br /> Relingwshedby (&7zt wdPenadrlem. Dale �� �I Time I Received by(sigaase .rdPmtedName) Date Tame <br /> Relinquishedby (sVm..wPkt Namet Date ii �i Time Received by(swwheeand Pdrtedrmma) Date Time <br /> I <br /> hereby authorize ATL to perlorm the work Send Report To Stil To Special InstructionslCommenis <br /> indicated belovri <br /> Protect Mgr/Submitter• Atte ��� �i '�- � Attn �J AMV $Z(oa :4'o CS, Q'P c K t r Z--Q C.A j A00 F-0 6 <br /> 0 <br /> co �� �� co w� GTteC ��ora LTMx--r err 5 <br /> 'S- 0 <br /> P !(Q�� <br /> J <br /> Pant Name Date i, ! <br /> Address II I Address <br /> snnature CI state II ZI II City State Zip <br /> Unless Otherwise Sample ArchrvelDisposal Circle or Add CIRCLE APPROPRIATE O A I Q C <br /> it Laboratory Standard Analyms(es) P <br /> MATRIX Z RTNE IN <br /> requested,all samples ❑ Other Requested <br /> will be disposed 45 days ❑ Return To a II II �m �� m` 1 c. J� �� 1-- ElEly� o� u O v0 ¢ WIP ❑ <br /> after receipt Q J , �, <br /> •$i0 00 FEE PER HAZARDOUS SAMPLE DISPOSAL ��k � �v Z. NAVY ❑ <br /> ` LAB USE ONLY a ii 2�c°g m=P � y�� a ��c�� e Contatner(s) CT ❑ <br /> T Batch# Sample Description I� a� �o �� �r ��` a tea' a w OTHER <br /> - <br /> Batch <br /> Lab No Sample I D Date Time m �" $ yo ��a'� 4e g �, a TAT # Type a REMARKS <br /> r ow - i �a-'i X X 3 V & e <br /> -zt4 Ow - li 3 V;G <br /> 1Kt <br /> MVJI� + P <br /> CIO c, <br /> ii <br /> 'i lit <br /> •TAT starts 8 a m following day if TAT A- Overnight 8 Emergency C Critical p_ Urgent E_ Routine Preservatives <br /> samples received atter 5 p m <br /> - <_24 hr Next Workda = 2 Workda s - 3 Workda s 7 Workdays H=HcI N_HNO3 S=H:SO. C=4 C <br /> Container Types T-Tube V--'VOA L=Liter P=Pint J--Jar B=Tedlar i G=Glass P=Plastic M=Metal Z=Zn(AC)2 O=NaOH T=Na2Sx0,3 <br /> it <br /> I <br />