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ASSOCIATED LABORATORIES LJ <br /> 806 North Batavia ■ Orange, CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 • Fax (714) 538-1209 <br /> Company, of r-1 ! L Pho fy� / 56 Z— 3 S f A L Job No 1[ K Page of <br /> Project Manager !� r Fax I2 {� Analysis Requested Test Instructions&Comments <br /> r r � i' f}1�tJ c�►�.t� �2� ���� �5 Y Q <br /> Protect Name � ��y� s�M�p -�� Project iY <br /> and Name <br /> Address bCA��H 0A „ <br /> Sample ID Lab ID Date Time Matrix ContainerPres <br /> Number/Size <br /> 0 l o t i 4� /�T 1 L 2 t' o >( X X <br /> 2 itl�truF �0 LLA os 10 'qC llV79- 4MOl-4fl 4944 X X <br /> 3 <br /> 4 00, <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 1A <br /> 15 <br /> Rehngwshe�d bby .� 1 Rehn�uished� 2 Relinquished by 3 <br /> Sample Receipt -To Be Filled By Laboratory sam ler TSL{ <br /> Total Number of Containers Properly Cooled Y/N/NA Sig�3` Signa(9V� �� Signature <br /> Custody Seals Y I N/NA les Samp Intact Y I N/NA Printed Name Printed Name Printed Name <br /> Received In Good Condition Y I N Samples Accepted Y IN Date 1 Time y Date Time Date Time <br /> Turn Around Time Received By i Received z Received By 3 <br /> t�►.A7�-1-1 �- <br /> Signature 1 Sign r nature <br /> LNorrnal Ll Rush ❑Same Day ❑48 hrs printed Name rD <br /> a Panted Name <br /> El 24 hrs ❑72 hrs l� <br /> s Date Time © rs Time 811 3S Date <br /> Orstnbution WhAe oratory Canary Laboratory Pink Project/Account Manager Goldenrod Sampler/Originator <br />