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r = = = = s = <br /> 806 North 8afatna ■ Orange, CA 9286 <br /> Chain of Custody Record Phorie r���� ���-t590Q Ft�rx 1714) 53$-�2Q9 <br /> company -r/40 O�4— � Phone�S fa.2t 3 7 A L Job No Page of <br /> Project PrManager Q JIU*UI4' Fax •r Analysis Requested Test Instructions&Comments <br /> Protect Name V /4 oaTw �2 �'�'MAt ;dG Protect 0 / <br /> Site Name 12 6-0 � . <br /> and <br /> Address ;0—FO C k"FAK,I e _. f <br /> Semple!D Lab!D Date Time Matsu Container Pros <br /> P <br /> Number/Size (� <br /> {I tlrl.F�r' 0a.01. 00 g'oo #t� <br /> 2 rhfG�`.� g f <br /> 3 12V 8 -60 <br /> 4 � . � <br /> K,- <br /> --1B 1w '�vX XX <br /> s 16 9V fD:gv <br /> 9 3111, 40 X k <br /> 10 <br /> ii <br /> 12 <br /> 13 <br /> 14 <br /> 1s <br /> Sample Receipt -To Be Filled By Laboratory IAelinquished by 1 Relinquished by Z Relinquished by 3 <br /> Sam ler <br /> Total Number of Containers Properly Cooled Y l N/NA /i_ Signature Signature Signature <br /> Custody Seals Y/N/NA ,VJ Samptes Intact Y 1 N/NA ,�� printed Name '-.� ^ p, Printed Name Panted Name <br /> Received in Good Condition Y!N Samples Accepted Y f N Date , �7t 00 <br /> Time Y Date Time Date Time <br /> Turn Around Time Received Or i Received By 2 Received ay 3 <br /> �/ Signature , Signature Signature <br /> . t Normal ❑ Rush 0 Sartre Day ❑48 hrs Printed r Printed Name Printed Name <br /> ❑24 hrs 0 72 hrs <br /> Date +me Date Time Date Time <br /> -ft <br /> OWWbutlon. White-Laboratory Canary-Laboratory Pink-Project/Account Manager Goldenrod-SanVler/Odginator <br />