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A.ssocrATED �t?TTy <br /> 80b North Batavia ■ 68 <br /> Chain of Custody Record Phone (714) 771-6900 a Fox (714) 538-1209 <br /> Company , ! r L CO <br /> ,/fi Pho t LJ2 � �7/ A L Job No C D + Page of <br /> Project Manager n � i9� Fax Jr��r {r--�'�.� Attalys:s Requested lest Instructions&Comments <br /> r <br /> Protect Name 4 Protect# I <br /> I� <br /> Site Name <br /> i2 �✓! C M <br /> and <br /> Address <br /> Sample ID Lab ID Date Time Matrix Container Pres <br /> Number/Size <br /> I <br /> 04,09- 0 J> 16,'0© 141-I- r40111k <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 10 <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished by 1 Relmqux �,ZM Relinquished by 3 <br /> Sam Ier <br /> Total Number of Containers l Properly Cooled Y/N/NA Signature Signature Signature <br /> Custody Seals Y/N/NA `Q- Samples Intact Y/N/NA Printed Name ���� Printed Name Printed Name <br /> sr--P- <br /> Received in Good Condition Y/N Samples Accepted Y/N Dat®f.� � icj?� Time �� r 4_0 Date Time Date Time <br /> ReB 1 Received By 2 Received By <br /> cery 3 <br /> Turn Around Time V, F 5;� <br /> / i. Signature Signatureal� L Signature <br /> C� 1 <br /> 'Normal ❑ RuSh ❑Same Day ❑48 ht's Printed Name Printed Name f� )f t{ Printed Name <br /> Ll 24 hrs ❑72 hrs �-]6 v <br /> Date Time Date _rVIl� Tim p Date Time <br /> Dtstnbutmn Wtuto Laboratory Canary Laboratory Pink-Project/Account Manager Goldenrod Sampler/Originator <br />