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Imo\ <br />Inter - Mountain Labs <br />Sheridan, WY and Gillette, WY <br />INTER- MOUNTAIN LABS <br />- CHAIN OF CUSTODY RECORD - <br />Page of 2 <br />All shaded fields must be completed. <br />This is a legal document, any misrepresentation may be corsirued as fraud. <br />#WEB <br />Client Name <br />ter 0�4 <br />Project Identification <br />/�of Q►� ReLI Af"i0r <br />Sampler (Signature /Attestati n of Authenticity) r� Telephone # <br />- k� (r2yar i�R S IC X170 &6 Z loi <br />Report Address <br />F0 Hox (01ST <br />N�c C I`t Z`f <br />Contact Name <br />- rr -<Var RaySct' l� <br />Email tf a� <br />4 5 <br />Phone cf v� � i b <br />ANAl <br />YSES <br />1 PARAMETERS <br />REMARKS <br />j <br />`n <br />Invoice Address <br />P,() S D (ol <br />D SS (� 2 <br />Purchase Order # <br />i ' SJ117 <br />Quote # <br />l `t`d 12- 7 <br />w <br />LAB ID <br />(Lab Use Only) <br />DATE TIME <br />SAMPLED <br />SAMPLE <br />IDENTIFICATION <br />Matrix <br /># of <br />Containers <br />5- 17 -►�i <br />1 S' �� <br />5 5— 7s� <br />5 �-- <br />I <br />X <br />�armw,��ers in ellow <br />� <br />� —� 7� ► `t <br />i �-t : � 3 <br />S S — 7 <br />5 c— <br />1 <br />x <br />T <br />55 7 I <br />5 <br />S S 7 <br />5 L <br />x <br />SHIPPING INFO <br />J UPS <br />J Fed Express <br />❑ US Mail <br />❑ Hand Carried <br />❑ Other <br />MATRIX CODES <br />water "IT <br />Soil SL <br />Solid SD <br />Fifter FT <br />Other OT <br />TURN AROUND TIMES <br />JCheck desired service <br />10 Standard turnaround <br />❑ RUSH - 5 Working Days <br />❑ URGENT - < 2 Working Days <br />Rush B Urgent Surcharges will be applied <br />COMPLIANCE INFORMATION <br />Compliance Monitoring ? Y / <br />Program (SDWA, NPDES_ ) <br />PWSID / Permit # <br />Chlorinated? Y kW <br />Sample Disposal: Lab Client <br />ADDITIONAL RENIARKS <br />_ <br />Jr, -)untain Labs, Inc. www.intermr •3bs.com Rev 4 6 <br />