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ASSOCIATED LABORATORIES LA\ <br /> 806 North Bat=a • Orange CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1209 <br /> Company —r vl L �V Phone(,-, 3�, E 1-10 1 <br /> I �.�'� A L Job No 5 Page of <br /> Protect Manager Fax <br /> � � rJ V �j-5 S6 �,�— Analysts Requested Test Instructions 8�Comments <br /> Protect Name , Pro eat � <br /> and NSiteame 12.5L7 .(1 l`L 14 W <br /> Address p <br /> Is <br /> C Y)- <br /> Sample ID Lab ID Date Time Matrix Container Pres } <br /> Number/Size <br /> t I^��GLI tF t O-1-V-1--o t 2.r ao l -I,I� ,�!1 -�1� i-1 dr, c �C X <br /> z i t4' 0 3-01---o !2.110 4-T-"LstD- �aH��� )L <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> i g <br /> 10 -1 14 <br /> 11 <br /> 12 <br /> 13 <br /> T-4 <br /> i5 <br /> Sample Receipt-To Be Filled By Laboratory sal gmplEfshed by�✓ � 1 Ret�nC hed b �1 �2 Relinquished by 3 <br /> Total Number of Containers Properly Cooled Y/N/ A Si rSignature Y ,�y�� Signature <br /> �V�ERHk0 rl <br /> Custody Seals Y/N/NA Samples Into Y!N/NA Printed Name � �� Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accept e Y/N ale —O 7—, � Time-1 <br /> f Date Time Date Time <br /> Turn Around Time fl feivediy V� 7�j�1 Received By 2 Received By 3 <br /> / <br /> Signature V ���fi Signature /--" <br /> Signature <br /> Ud Hormal ❑ Rush 0 Same Day ❑48 hrs Printed Name Printed Name Printed Name <br /> El 24 hrs ©72 hrs -L,p1v/C L <br /> Date Time Date Time Pis Date Time <br /> Distribution White Laboratory Canary laboratory Pink Project/Account Manager Goldenrod Sampler/Onginator <br />