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n <br />CHAIN Or CUS'T'ODY <br />Accutest Job #: D5570OX <br />CIACCUTEST. 4036 Younglield St., Wheat Ridge, CO 80033 Accutest Quote #: 0 <br />303 -425 -6021 FAX: 303425 -6854 AMS P.O. #: <br />Project No.: <br />Client Information <br />Subcontract Laboratory Information <br />Analytical Information <br />Name <br />Name <br />Accutest Mountain States (AMS ) <br />Hazen (Radiological) <br />O <br />Address <br />Address <br />4036 Youn field St. <br />4601 Indiana Street <br />m <br />City State Zip <br />City State Zip <br />Wheat Ridge, CO 80033 <br />Golden CO 80403 <br />@ <br />m <br />Send Report to: Scott Heideman <br />Contact: <br />Any questions contact: Renea Jackson <br />Sample Management <br />_n <br />Phone/Fax #: (303) 425 -6021; (303) 425 -6854 <br />Phone: (303 ) 279 -4501 <br />Collection <br />Preservation <br />#of <br />U) <br />O` <br />J <br />0 <br />p <br />n <br />c <br />Field ID / Point Of Collection <br />Date <br />Time <br />Matrix <br />bottles <br />= <br />z <br />= <br />= <br />z° <br />C7 <br />Comments <br />D5570OX -1 <br />3/6/14 <br />1:24 PM <br />AQ <br />3 <br />X <br />Turnaround Information <br />Data Deliverable Information <br />Comments / Remarks <br />O10 Business Day Standard Approved By: <br />❑ Commercial "A" O PDF <br />Please use Colorado <br />Other (Days) <br />F-1 Commercial "B" F-] Compact Disk Deliverable <br />regulations and RLs. <br />Commercial "BN" Q Electronic Delivery: <br />❑ Reduced Tier 1 0 State Forms <br />10 Day Turnaround Hardcopy, RUSH is FAX Data unless previously <br />0 Full Tier 1 E-1 Other (Specify) <br />approved. <br />Sat'nple Custody must be documented below each time samples <br />change possession, including courier delivery. <br />For Subcontract Laborartory Use Only <br />e i s hed b7.- <br />a e e: <br />ecea y: <br />r- <br />a e ime: <br />ea <br />ea space: <br />�7 <br />I,-{ <br />1 <br />�A <br />? i /7 <br />Yes ❑ No ❑ NA ❑ <br />Relinquished y: <br />UaT <br />Kecervec 13y: <br />Date & I ime: <br />reserve w ere app ica e: <br />2 <br />2 <br />2 <br />❑ <br />Relinquished <br />uate & Time* <br />Received By: <br />Date & Time: <br />On Ice <br />3 <br />3 <br />3 <br />Temperature °C ❑ <br />C14�o <br />0W: <br />00U� <br />Ux <br />Q S <br />N <br />