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ADZ <br /> Laboratories, Inc 3 • ' <br /> 2773 Downhill Drive Steamboat Springs, CO 80487 (800)334-5493 <br /> of a. <br /> Name: r Addres°°s"":�� �-} 1'lt t. <br /> Company: a <br /> E-mail: d Tele hone: _'5 0 _ <br /> Copy of Reportto: <br /> Name: -f E-mail: OL <br /> Company: 1CLQy Telephone: <br /> Invoice to: <br /> Name: n Address: 1-1 ► - <br /> Company: to <br /> r� <br /> E-mail: Telephone: <br /> If sample(s)received past holding tiM HT),or if insufficient HT remains to complete I YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? ( NO <br /> If"NO"than ACZ will contact client for further Instruction. It neither"YES"nor"NO"Is Indicated,ACZ will proceed with the requested analyses,even If HT Is expired,and data will be qualifletl <br /> Are samples for SDWA Compliance Monitoring? Yes I I No <br /> If yes,please include state forms.Results will be reported to PQL for Colorado. <br /> Sampler's Name:SA !�4� Sam ler's Site Information State l Zip code Time Zone <br /> tt <br /> 0 'I aest to the authenticity and validity of this sample. I understand that mislabeling the time/date/location,or tampering <br /> 'Sampler's Signature: ��� with the sample In anyway,Is considered fraud and punishable by State Law. <br /> PROJECT • • • a(attach list or use quote number) <br /> Quote#: !'JU <br /> is <br /> Reporting state for compliance testing: ��) c <br /> U <br /> Check box if samples include NRC licensed material? c <br /> 14 <br /> i <br /> f <br /> q11TffXq 1030 111 <br /> YYLo - . P <br /> w <br /> �I 006W <br /> C C Matrix SW(Surface Water) GW(Ground Water)•WW(Waste Water)•DW(Drinking Water)-SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> r <br /> Please refer to ACZ's terms &conditions located on the reverse side of this COC. <br /> • D• • D• <br /> IV <br /> 0I9l1fbh%3 White-Return with sample. Yellow-Retain for your records. Page 22 of 23 <br />