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r r AM EE101BOWNWESM <br /> 806 North Bata me r ■ Orange CA 92868 q <br /> Chaint Custody Record Phone (7I4) 771-6900 ■ Fax (714) 538-7209 <br /> Company Phone 11 <br /> A L Job No Page l of <br /> Project Manage,'W1 Fax "i5 Analysis Requested Test Instructions& Comments <br /> 1 1 r <br /> Project Namev,10 1 1 p <br /> Site Name <br /> and D <br /> ti1�0 1� \ CPS <br /> Address <br /> Container _ t <br /> Sample ID Lab ID Date Time Matrix Pres D <br /> Number/Size <br /> L <br /> Sal L ` <br /> zD_ 6 <br /> Poe3 <br /> 4 <br /> s 30 1 la)Q a� <br /> g b- o o�.c� pC <br /> wSD^ qS <br /> 10 so Z � <br /> 11 , 55 33 a <br /> 12 eoasv(;10 AVO <br /> 13 t JSC)' 65 o v <br /> 75 �/\ <br /> �J Sample Receipt-To Be Filled By Laboratory Relinquished by 1 Relinquished by 2 Relinquished by 3 <br /> Sam ler <br /> Total Number of Containers Properly Cooled&I NA tura Signature Signature <br /> Custody Seals Y/N/NA Samples Intact/NA P� Nae Printed Name Printed Name <br /> Received in Good Condition Y/N Samples Accepte /N Date Time�,1 Date Time Date Time <br /> Turn Around Time Receive Received By 2 Received By 3 <br /> Signature Signature Signature <br /> ormal ❑ Rush ❑Same Day 0 48 hrs punted Name Printed N e Panted Name <br /> D 24 hrs ©72 hrs o N 6 V,.,, <br /> Date Time Date Time Date Time <br /> L <br /> Distribupon White Laboratory Canary-Laboratory Pink Project/Accounl MReriager Goldenrod-Sampler/Originator oil <br />