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AMCIWEANNABIMI <br /> �- 806 North Batavia ■ Orange CA 9286 <br /> ChaigolY <br /> f Custody Record Phone (714) 771-6900 • Fax (714) 50, 09 <br /> Company iJI11 Phone A L Job No Page ! of <br /> Project Manager) Fax Analysis R59gested test Instructions 8i Comments <br /> Project Name Project N <br /> J <br /> Site Name ` 1 � ' <br /> and 1 <br /> Address <br /> Container <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres <br /> W T s q- 1 <br /> 4 <br /> fi <br /> 7 <br /> S <br /> 9 <br /> 10 <br /> .r <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> r Sample Receipt-To Be Filled By Laboratory Relinquished by �r_L7 U— 1 Relinquished by 2 Relinquished by 3 <br /> Sampler <br /> Total Number of Containers ' Properly Cooled Y 1 N I Signal Sigriature Signature <br /> Custody Seals Y!N/NA Samples Inta N/NA Panted N Panted Name Panted Name <br /> Received in Good Condition Y/N Samples Accepted&N Date Time r Date Time Date Time <br /> Turn Around Time Received By 1 Received By 2 Received By 3 <br /> r Si a Signature Signature <br /> Normal ❑ Rush 0 Same Day 0 48 hrs Pnn ame_ Printed Nae Printed Name <br /> ❑24 hrs ❑72 hrs ma tJ6 <br /> r patLTime •, ] Dake C Time Date Time <br /> Z ` n <br /> Distnbution White Laboratory Canary laboratory Pink-Project/Account Manager Goldenrod Sampler/originator <br />