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ASSOCIATED LABORATORIES <br /> 806 North Batavia • Orange, CA 92868 <br />` Chain of Custody Record Phone (714) 771-6900 • Fax (714) 538-1209 <br /> Company�1 Phon / A L Job No i Page of <br /> Project Man�ag�rellr rL Fax2� Analysts Requested Test Instructions&Comments <br /> Protect Name /1, S G�_R i\ ii�� Project# <br /> Site Name 2 T } W L w <br /> and <br /> Address <br /> Container 9 <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres <br /> S <br /> lg nv) X <br /> �2 w%- 5 x <br /> ,- � - ► ©� <br /> 5 P� °�v • t o+ X u <br /> r V . <br /> 7C <br /> . Y yc <br /> 16 j� �1 . � :1 `x SC <br /> 12 f- rGUr. 11'•k <br /> 13 ! FGv • f t :s yc �c <br /> 14 <br /> 15 <br /> Relinquish e b ♦ 1 Rehn rshed b 2 Relinquished by 3 <br /> Sample Receipt-To Be Filled By Laboratory sem ier �'L' <br /> Signature Signature ,, pt� _ Signature <br /> Total Number of Containers Property Cooled Y/N/NA ()11 <br /> Pry gine Panted Name Printed Name <br /> Custody Seals Y/N/NA Samples Intact Y/N 1 NA yt L�fJQt Cv <br /> Qat Time t Aate Date Time <br /> Received in Good Condition Y/N Samples Accepted Y!N r �p 1,7 <br /> R ce ed y 2 R fired By 3TurnAround Time -pmt -0 <br /> Signature . ,p -- � ignaiure❑Same Day U 48 hrs Pted Name Panted Name <br /> F40rmal ❑ Rush t7e 1` I <br /> ❑24 firs ❑72 firs Time <br /> Time � Time ��,� Date <br /> L 0 — 1 <br /> _ I . . - --- .--...,, 01nk P—I.M/Arrrnmt Manager Goldenrod Sampler/Originator <br />