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ASSOCIATED LABORATORIES LA <br /> 806 North Batavia • Oronge, CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 w Fox (714) 538-1209 <br /> Company 7wPa'FiFI 01 L- c _ Phon �-J5 A L Job No 014,05-- <br /> Page of <br /> 5 <br /> Project Manager Fax -.- �/ �� ^� Analysts Requested Test Instructions&Comments <br /> Project Name V <br /> � L � , p I ' n Protect# ©��f07,"0D <br /> Site Name 0" 1 W 1 t/ �l�f W�T �'l� �'iJ I <br /> and <br /> Address 5rOC14710 I n 16-2-057 - 4 ' I <br /> ID Lab €D Date Time Matrix Container Fres C4 C� -� <br /> SampleNumber/Size <br /> ' Al oB4-cAj h.K o 4-VOA- �[Gf• X X IhY Sas Q ui12r�D <br /> 2 - — o ,3 oX Okg�'iP�� CvMPov�A� <br /> s r►lu9- x )< u5F6 Iq CA G SD0r4rz- <br /> 4 LV'4 �[ 0 ?� )< ?< f3 $260$ <br /> 5Ra- $ 16't Oct <br /> 16r � /x - � �FI�o1. <br /> )6,10 X <br /> ice- X6'4 <br /> 10'x i) mo 00 <br /> 11 <br /> 12 r2- <br /> t3 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By laboratory SamplerRelinquished by I!\,t 1 Rel+nqu shed by L , 2 Relinquished by 3 <br /> Total Number of Containers 1 Properly Cool Y! /NA Signa f'{ Signature !s-P-q� t f3�r Signature <br /> Custody Seals Y/N/NA Samples Into Y!N/NA Panted me Panted Name Printed Name <br /> ��- <br /> Received in Good Conddion Y/N Samples Accept / Dat Time Date Time Date Time <br /> Turn Around Time Recet�,BX r`` 5 I Received By 2 Aecervg�ey s <br /> Signature 4 Signature Signature <br /> �Nowl ❑ Rush Ll Same Day ❑48 hrs Panted Name Printed Name ;t L \.,U Printed Name <br /> ❑24 hrs ❑72 hrs <br /> ` Q Time Date Time VZ, <br /> Date Timp,i�� <br />