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ASSOCIATED LABORAT�I� <br /> 806 North Batavia ■ Orange CA 928458 <br /> Chdih of Custody Record Phone (714) 771-6900 ■ Fax (714) 538-1209 LM\ <br /> Company 0 cr— Phone eFclz/ <br /> (per/ —0,3�D A L Job No l f Page of - <br /> Project Manager 0,0 C.1 V t-4Fax <br /> l `�[ <br /> 2,( "' Analysis Requested Test Instructions& Comments <br /> Project Name 140 ! �t <br /> Site Name � V ��-�•t !( � � p <br />� and <br /> Address 1 <br /> Sample ID Lab ID Date Time Matrix Container Pres E <br /> Number/Size C <br /> ' F-,f -N oo <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> . 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be rilled By Laboratory Relinquished by � Retluiahed. by � ?� Relinquished by 3 <br /> Sampler rid l► 8 r•r i <br /> Total Number of Containers Properly Cooled Y/N Signature Signature Signature <br /> !Pb Printed Name Printed Name <br /> Custody Seals Y l NA Samples IntaC Y /NA Printed Nam W ryr <br /> Received in Good Condition N Samples AocepteoN Date 0 <br /> 2•9'A L Time /G r Date Time Date Time <br /> Turn Around Time Received sr Received By- 2 Received By 3 <br /> z <br /> Signature Signature Signature <br /> I <br /> LAormal - ❑ Rush 0 Same Day 0 48 hies Printed Name Printed Name ,,6 7-'J� Printed Name <br /> ❑24 hrs ❑72 hrs <br /> Date Time Date Time I v I Date Time <br /> i Distributm White-Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />