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= 0% = = = = = = M E1B�lA <br /> J4806 North Bata wa • Orange, CA 928b <br /> Chain of CustodyRecord <br /> Phone (7I4) 771-6900 w Fax (7I4? 538-I2Q9 <br /> Companyft-�`�/ Ph o 6 2 2�'—3„J�' kL Job No Page of <br /> Proiect Manager iG�� � Fax Analysis Requested Test Instructions Comments <br /> Prosect Name ,f JLY fy (L' Protect# <br /> Site Name <br /> and <br /> Address Gro C ieGoz4 C4, h 5— P i l <br /> Sample ID Lab ID Date Time Matrix Container Pres F <br /> Number/Size <br /> 2 ,e-( U/✓ <br /> a -B 9 V <br /> ✓ q <br /> 4 W✓ LD:ev x x x <br /> x x <br /> & J 6 1`A�✓ <br /> 10,5'0 ><,X <br /> go <br /> ,a <br /> 11 <br /> 12 <br /> 13 <br /> 14 <br /> ,5 <br /> Sample Receipt-To Be millet!By Laboratory Relinquished by 1 Relinquished by 2 Relinquished by 3 <br /> Sampler <br /> Total Number of Containers Properly Cooled Y/N/NA Signatures Signature Signature <br /> Custody Seals Y 1 N/NA Samples Intact Y/N 1 NA Printed Name Printed Name Printed Name <br /> Received in Good Condition Y 1 N Samples Accepted Y 1 N Date Time Date Time Date Time <br /> Turn Around Time Received By 1 10 Reserved By 2 Received By 3 <br /> Signature Signature <br /> 4Alr Norma! ❑ RushU Same Day ❑48 hrs mPnnted Name Printed Name <br /> Ll 24 his. ©72 lira J <br /> f27 <br /> �a Date Time Date Time <br /> Distribution White laboratory Canary Laboratory Pink-Pro]acVAccount Manager Goldenrod-Sampier/Orig/fistor <br />