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ASSOCIATED LABORATORIES JA\ <br /> 806 North Batavia ■ Ortmge, CA 92868 <br /> M Chain of Custody Record Phone (714) 771-6900 • Fax (714) 538-1209 <br /> Company HiQ./ 0I L C Pho 62 92 ���4 AL Job No 7�- Page of <br /> Protect ManagerIaFf� <br /> F 6z '7-1V^ Analysis Requested Test instructions&Comments <br /> � <br /> Project Name Now?-(U/ W is `. Prot t# <br /> aSde <br /> nd Name 12- ,6 • LU1 L5t*,' tI(•(� �✓ V 1 f <br /> Address Z►TZ)eIC-I W 04 f 1_ <br /> Sample ID Lab ID Date Time Matrix Container Pres. FG-- <br /> Number/Size <br /> Pmri lea XX XI <br /> 2 r <br /> s —M e) U/ <br /> LP:00 <br /> 5 4t :[oK X,X <br /> 6 3 p; <br /> 7 <br /> 6 <br /> g <br /> 10 <br /> 11 <br /> i <br /> 12 <br /> 13 ' <br /> 14 <br /> 15 <br /> t <br /> Sample Receipt-To Be Filled By Laboratory sampleRelinq [shed by 1 Relinquishedy� 2 Relinquished by 3 <br /> Sam ler- <br /> Total Number of Containers Property Cooled Y/N/NA Signature Signature Signature <br /> Custody Seals Y/N/NA Samples Intact Y/N/NAA Printed Nam ex-N Printed Name Pnnted Name <br /> Time <br /> Aecered in Good Condition Y/N Samples Accepted Y/N Dat�-1JA,, Date tine Date Time <br /> Turn Around Time Received By. <br /> 11FI 1 Received By 2 Received By 3 <br /> Signature Signature Signature <br /> ❑Same Day ❑48 firs Pnnted Name Pnnted Name Pnnted Name <br /> YNormal ❑ Rush ❑24 hrs o 72 hrs Wo N G v V <br /> Date Time Date Time Date e <br /> � .. _ _._ ..____ •_�___•_., m..� n......,•�w...,.....a u......,...r !`nldnnrr•A Swmnlorlrl.[ninar,x <br />