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ASSOCIATED LABORATORI <br /> 806 North Batavia ■ Orange CA 92868 <br /> Chain of Custody Record Phone (7I4) 771-6900 i, Fax (714) 538-1209 LM\ <br /> Company `��f] . f-- 0 f�— CIO Pho�F]��2 C`{q `— A L Job No �}� 1"� Page of y� <br /> Protect Manager 3(•f ; P �],J�l <br /> a F �.� gy l ���L-� Fax <br /> Analysts Requested Test Instructions & Comments <br /> Project Name1 ` Project k <br /> �[� 'add I�t,�(�r���-- i 174 <br /> Site Name <br /> and �J <br /> Address <br /> Container -P <br /> Sample 10 Lab ID Date Time Matrix Number/Size Pres f <br /> i <br /> C72 (9 02- 9'60 Ib P-- Jif-T d - floY , <br /> 2i. `< <br /> U ✓ t�' <br /> 10 <br /> 11 <br /> 12 .� <br /> 13 <br /> 14 <br /> t5 <br /> Sample Receipt -To Be filled B Laboratory Relinquished by P 1 Relinquished by 2 Relinquished by 3 <br /> p p y Sampler <br /> �ff�r�� ly , <br /> Total Number of Containers Properly Cooled Y/N/NA Signature Signature Signature <br /> Custody Seals Y I N/NA Samples Intact Y I N/NA Printed Namee ` M Printed Name Panted Name <br /> Received in Good Condition Y/N Samples Accepted Y IN Date O 2.Vq-r D L Time ) T'1'-'1-GO <br /> Date Time Date Time <br /> Turn Around Time <br /> Received By ori _fit !4 T 1 Received By 2 Received By 3 <br /> Signature Vim' �% Signature PAY—r---1 <br /> Signature <br /> L� Normal ❑ Rush 11 Same Day 0 48 hrs Panted Name Printed Name I 1 9 Printed Name <br /> Ll 24 hrs ❑72 hrs ��C��� <br /> Date Time Date Time Dale Time <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />