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5550 MOREHOUSE DRIVE , s <br /> J�AnalyticalTechnologies,lnc SAN DIEGO, G4 921211709 Chainf <br /> (619)4589141 o Custody DATE? PAGEj— OF L <br /> PADDRESS <br /> ANAGER r �^ Recommended Ouantity and Preservative (Provide triple volume on OC Samples) <br /> �— <br /> o, a g <br /> 2 Rl- I R) _6"', <br /> ti N N O r, O d Q Q E 4 6 0 4 <br /> BILI TO �" v v N N N N N g ] N j g <br /> v� <br /> COMPANY o 0 0 0 ! <br /> ADDRESS <br /> C� c a co 2 4 <br /> v $ ` E `a o o `m `m• U m c <br /> c�c3 c a $ U C3 E INCU <br /> - b, <br /> SAMPLERS (Signature) PHONE NUMBER O v h 2 b o a o ? v <br /> E <br /> m Za u� `Qi m m q ani -74; ;b 'o <br /> �- U m o <br /> SAMPLE ID SAMPLE o o w = t 'O `�' c z"' =' b <br /> m H o — o w o o � m 1u � ' <br /> DATE TIME' MATRIX LAB ID � � � a �� 917 � � � � v� � � �� <br /> 022 s -��z A l Vil-I F 7 z Z <br /> i <br /> PROJECT INFORMATION SAMPLE RECEIPT RELINQUISHED BY ! REtINOUISNED BY 2 RELINQUISHED BY. 3. <br /> PROJECT NUMBER TOTAL NUMBER OF CONTAINERS ignature Trme Signature Time Signature Time <br /> PROJECT NAME A s > it CHAIN OF CUSTODY SEALS YIN/NA Y 11 <br /> U� <br /> Panted Date Printed Name Date Printed Name Date <br /> PURCHASE ORDER NUMBER SEALS INTACT? Y/N/NA LI r , . 2 - C,c' <br /> VIA RECEIVED GOOD CONA/COLD Company Company Company <br /> TAT❑24HR❑48HRS❑72HRS❑1WK❑2WK LAB NUMBER �_t -7 Sly <br /> SAMPLE DISPOSAL INSrRUMOIYS RECEIVED BY f RECEIVED BY 2 RECEIVED Br(LAB) 3 <br /> a1.4 Time Signature Time Signature Time <br /> El ATI Disposal @ $500 each ❑ Return E7 Pickup Q <br /> Comments int Name D to Printed Name Date Printed Name Date <br /> /! Z <br /> Co pany Company Analytical Technologies,Inc <br /> DISTRIBUTION White Canary ANALYTIC4L TECHNOLOGIES INC •Pink ORIGINATOR <br />