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ASSOCIATED LABORATORIES <br /> 806 North Batavia • Oiange CA 92868 <br /> Chain of Custody Record Phone (714) 772-6900 ■ Fax (714) 538-1209 <br /> Company7 t <br /> Phon� 3 A L Job Na 1 G i� ��� ��.,� <br /> Protect Manager _ , Fax Page of <br /> L Analysis Requested Test Instructions&Comments <br /> Protect Name f yy 1 , <br /> f I! ! 1_3 f Protect# <br /> Site Name �- <br /> and f'r {�, f - �'�! UL t <br /> Address J/ J j <br /> e <br /> Sample ID Lab ID Date Time Matrix Container Pres r' <br /> Number/Size C1 ✓ S <br /> A) �'t; i j' !T'L `C <br /> ! X <br /> 2 <br /> 3 n <br /> 1 \� <br /> A � <br /> 5 �f I <br /> 6 <br /> r <br /> 7 <br /> } <br /> 8 r <br /> t <br /> 10 J� f <br /> 1 <br /> r <br /> 1a <br /> 12 f <br /> f � <br /> i <br /> 13 <br /> 14 <br /> Sample Receipt-To Be Filled By Laboratory Seim quashed by t Relinquished � � Relinquished by 3 <br /> er <br /> Total Number of Containers Properly Cooled Y/N! A Sign fe, , Signature , Signature <br /> t� � 0�'t~t2l�IG47fi <br /> Custody Seats Y/N/NA Samples Int t Y/N/NA printed Name Printed Name <br /> P , > > ,`� Panted Name <br /> Received in Good Condition Y!N Samples Acceple N Date �- r Time / Date Time Date Time <br /> 'turn Around Time Received By _ 1 Received By 2 Received By 3 <br /> r-d l OiC-14 i r-r R-_ <br /> Signature Signature Signature <br /> 0l <br /> Ll Norma! ❑ Rush D 24 his ❑72 i'r�-trlrtr ilf <br /> Ll Same Day 0 72 his hrs Printed Name Printed Na e <br /> Panted Name <br /> 40ate Time Date Time Date e <br /> Lf L <br /> 3fn to ra ory Canary abora o ink P coun pr G f �I <br />