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ASSOCIATED LABORATORIES JA\ <br /> 806 North Batcmar ■ Orcmge, CA 92868 <br /> Chain of Custody Record Phone (714) 771-6900 • Fax (714)538-1209 <br /> Phan � 3hf l f fJ Page of <br /> Company rj,� � � � � A L Job No <br /> Protect Manager �1_/ �... Fax ��,� j,Lt� Analysis Requested Test Instructions&Comments <br /> e) t p <br /> Prosect NamroiectSite e <br /> and Name L- ter '�l�'� <br /> Address es 13 E t 652-66 <br /> Container <br /> Sample ID Lab ID Date Time Matrix Number/Size Pres' <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 41 <br /> I <br /> 12 <br /> 13 <br /> 14 <br /> 15 , <br /> Relinquished by 1 Reltn rsh tsX Relinquished by 3 <br /> Sample Receipt- To Be Filled By Laboratory Sam ter 1b t;(L1 � <br /> Signal �� Signature F t� Signature <br /> Total Number of Containers Properly Cooled Y/N/NA g <br /> Print p Printed Name Printed Name <br /> Custody Seals Y!N/NA Samples Intact YIN 1 NA <br /> e_ %,v> r Date a Date Time <br /> Received in Good Condition Y 1 N Samples Accepted Y IN Dat[v c Time <br /> Re c ed By� "-:� *R-eceiv6d <br /> Received By 3 <br /> Turn Ardund Time ��JJ40Signature ature <br /> rSame Day ❑48 hrs Printed Name Printed Name <br /> I�lormal ❑ Rush J 24 hrs ❑72 hrsDate Time L` t CfZ <br /> p Date Time <br /> Distnbubon Wh ratory Canary Laboratory Pitch Project/ACCount Manager Goldenrod Samplerlonginalar !� <br />