Laserfiche WebLink
J�I Inter - Mountain Labs <br />• s Sheridan. WY and Gillette. WY <br />INTER - MOUNTAIN LABS <br />- CHAIN OF CUSTODY RECORD - <br />Page 1 of Z <br />All shaded fields must be completed. <br />This is a legal document any misrepresentation may be construed as fraud. <br />#WEB <br />Client Name <br />e -+erh F4:(' d DYa 0 <br />Project Identificatirro��n / <br />0� 'R RC_/_ w <br />Sampler (Signature /Attestation of u enticity) Telephone # <br />-�✓yl Il � 11•evor Pac54 le <br />Report Address <br />ID D 60'y (c L <br />/V,A c a L U <br />Contact Name <br />T-gYo/ - <br />Email <br />Phone .7- <br />ANALYSES <br />/ PARAMETERS <br />REMARKS <br />'y <br />`n <br />+ <br />v <br />S <br />�� <br />f <br />o <br />-- <br />o <br />o <br />S <br />°- <br />Invoice Address <br />{� U gJX �� � <br />A / u L (,,r C U 2'-i <br />Purchase Order # <br />1 � S I 7 <br />Quote # <br />I H 1 Z` <br />LAB ID <br />(Lab Use Only) <br />DATE TIME <br />SAMPLED <br />SAMPLE <br />IDENTIFICATION <br />Matrix <br /># of <br />Slt{68 <br />fS'S -1 <br />45 <br />F T � U � <br />S 1— <br />x <br />x <br />t <br />v <br />x <br />x <br />5e< Add 4;mtvl /lr��rks <br />Sl D <br />- I) -1i{ <br />15.Z2 <br />5 S % (p <br />5 L— <br />rContainers <br />n raw,tfFrS In etid" <br />cud <br />�- -► � <br />� 3� 3� <br />S S - � <br />S �-. <br />K <br />�S-S -I�t <br />13' SAS <br />S- 7 2 <br />5 L <br />I <br />k <br />- <br />a <br />• <br />Ll UPS <br />❑ Fed Express <br />❑ US Mail <br />❑ Hand Carried <br />❑ Other <br />MATRIX CODES AROUND TIMES <br />Water WT heck desired service <br />Soil SL Standard turnaround <br />Solid SD ❑ RUSH - 5 Working Days <br />Fitter FT ❑ URGENT - < 2 Working Days <br />Other 01 Rush & Urgent Surcharges will be applied <br />COMPLIANCE •- • ADDITIONAL REMARKS <br />Compliance Monitoring ? Y / aw I e - f zvI" t 5 t rt i 1't <br />Program (SDWA, NPDES, P 1.2 u 5 e S u z tot Feirt; 1 i icr <br />PWSID / Permit # r.tL r r; a f< a n J <br />Chlorinated? Y / ro 0J. t're.. a � ar <br />Sample Disposal. Lab ✓ Client ` ot In a t , <br />Inter - Mountain Labs, Inc. www. intermou ntai n labs. corn Rev 4.6 Web <br />