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ASSOCIATED LABORATORIES <br /> 806 North Batavia ■ Orange, CA 92868 <br /> Chain of Custody Record Phone (714) 772-6900 • Fay (714) 538-1209 LA <br /> Company T7J�, ©I Phon 6 / 3 Jf p / A L Job No 12 r r Page of <br /> Project Manager -ii Fax 7 Analysis Requested Test Instructions&Comments <br /> b &)PYA �M r�- �6 `�2{��5tiv y q <br /> Project Name Project# <br /> Site and Name 4 <br /> )16-0 <br /> rl � ©t a! H w f f.so q LV 4 <br /> Address P ��� �h rya <br /> c) <br /> Sample ID Lab ID Date Time Matrix NContainer <br /> Size Fres no, <br /> to-dtf 9 bo P- TFza#2. ani X <br /> z (R- 12,V 1140 ?<l x <br /> 3 Tip,— q;50 XXIX { <br /> i0. Lo. x,X <br /> C >-9V 30 X X K <br /> (� -qw 0' -< X <br /> 7 <br /> V f <br /> - g WIt x/-,< <br /> x <br /> t' -r �� ,rp x X <br /> ,z IF--ff-[.UF--t49'.00 <br /> 13 IP <br /> ,5 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by— <br /> t Retrnc�,utsh?dd by 5 7 2 Relinquished by 3 <br /> Sampler <br /> [�0 <br /> Total Number of Containers Property Cooled Y/N/NA Signal a Signature Signature <br /> Custody Seals Y/N/NA Samples Intact Y/N/NA Pnnt��(Vam �,�)orp_ Panted Name Panted Name <br /> Received in Goad Condition Y/N Samples Accepted Y/N Da J!� r 0�n� Time /�.�tr� _ Date Time Date Time <br /> 'turn Around Time Received 8y1ag onrz(� 1�7 R calved By 2 Recelved By 3 <br /> SignatureV,Q-"1 in Signatu Signature <br /> tb f--1� <br /> Normal ❑ RuSh El Same Day ©48 hrs Pnnted Name Printeda Ger SIS Printed Name <br /> ©24 hrs (3 72 hrs <br /> Date Time Date I Time rr 3a Date Time <br /> "[ <br /> _DlstrityRion.—VW tory J0 pink-ProfeWftcount Manager Goldenrod Sampler/Origin <br /> I• t• l� tlil� <br />