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ASSOCIATED LABORAT017I <br /> 0 1 806 North Batavia ■ Orange, CA 92868 wA <br /> Chain of Custody Record Phone (714) 771-6900 . Fax (724)5.38-1209 <br /> CompanyPh }j G c �# 3 A L Job No t ��� Page � of <br /> 5^ P� 1 � <br /> pmjeci Manager Faxk 1� t 1.) Analysis Requested Test Instructions&Comments <br /> Project Name , a Pl�r-ol�ect <br /> Site Name r4 W <br /> and _ f <br /> Address S ,CX r--Z, t�f1 <br /> Sample ID Lab Ip Date Time Matrix Container Pres <br /> Number/Size <br /> x <br /> Ts <br /> 4 n< <br /> 6 � <br /> �2- tit , 'C <br /> yam- <br /> 12 <br /> 13 <br /> 14 <br /> 15 <br /> Relinquished y 1 7Si <br /> by Relinquished by 3 <br /> Sample Receipt-Ta Be I"illed By Laboratory sam lar � L .tSignat rnature Stgnalure <br /> Total Number of Containers Properly Cooled Y!N f NA � f <br /> Printed N me, r� � r^ 1� Pnnted Name Printed Name <br /> Custody Seals Y/N!NA Samples Intact Y/N/NA �_,tL r �.� c " <br /> me <br /> Date i � Time �'� _ Date Time Date Time <br /> Received in Good Condition Y!N Samples Accepted Y/N 01 <br /> Received B <br /> Received By- <br /> Turn <br /> Received t3y 9 <br /> Turn Around Time C L 1) <br /> signature Signature Signature <br /> L <br /> ❑Same Day E)48 hrs Printed N Printed Name Printed Name <br /> orm81 ❑ Rush # <br /> ©24 his ❑72 hrs pate Z � Time � Date Time Date Time <br /> u � <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod SamplerlOriginator <br />