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806orth rnna • rcm e, <br /> Chain *Custody Record Phone (714) 771-6900 r Fdx (714)17*7 <br /> Company Phone 5 J A L Job No ����l Page__J_of j <br /> Project Manager Fax Analysis Requested Test Instructions &Comments <br /> Project Name Project# <br /> VQ <br /> Site Name ` <br /> and 1 � <br /> Address O \_� <br /> Sample 10 f Lab ID Date Time Matrix Container Pres <br /> Number/Size <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> t3 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Salm ler uished by Relinquished by 2 Relinquished by 3 <br /> Total Number of Containers Property Co°i Y N/NA Signa Signature Signature <br /> Custody Seals Y/N 1 NA Samples luta Y 1 NA P Panted Name Panted Name <br /> Received in Good Condition Y/N Samples Accepte DateO Time Date Time Date Time <br /> Turn Around Time Received By 1 Receiy y 2 Received By 3 <br /> Signature Signature Signature <br /> Normal ❑ Rush U Same Day ❑48 hrs Printed NamePrinted Name Panted Name <br /> ❑24 hrs ❑72 hrs 0�6� <br /> Date Time Date Time Date Time <br /> 12� is 1 <br /> Distribution Wfute Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Samplerloriginator ;;7-;/() <br />