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ADZ Laboratories, Inc.�� j •' <br />2773 Downhill Drive Steamboat Springs, CO 80487 (800) 334-54 <br />-ae e <br />Name: Address: Pa flox 16]i1,3 <br />Company: �— <br />E-mail: Telephone: • <br />Copy of Report <br />Name: , E-mail: <br />Company: LLQ Telephone: -40P-1 ,0 <br />Invoice to: <br />Name:—� Address: 2 <br />Company: LL <br />2- <br />E -mail: ` , <br />✓ <br />Telephone: .126 <br />If sample s) received past holding time (HT), or if insufficient HT remains to complete YES <br />analysis before expiration, shall ACZ proceed with requested short HT analyses? NO <br />If "NO" then ACZ will contect client for further Instruction. If neither "YES" nor "NO" is indicated, ACZ will proceed with the requested analyses, even if HT is expired, and tlata will be qualified <br />Are samples for SDWA Compliance Monitoring? Yes No <br />If yes, please include shAe forms. Results will be reported to PQL for Colorado. <br />Sampler's Name: M mpler's Site Information State Zip codeA!2&2Time Zone; <br />'1 attest to the authendcity and validity of this sample. I understand that intentionally mislabenng the bmeldstellocadon or <br />*Sampler's Signature: tamperMg with the sample in anyway, Is considered fraud and punishable by State Law. <br />PROJECT•R• <br />Quote #: <br />PO#: <br />co <br />Reporting state for compliance testing: <br />t� <br />Check box if samples include NRC licensed material? c <br />tV <br />610 <br />3 <br />VA <br />3 2� 14f' <br />3 <br />✓77 <br />&,A sW <br />v <br />Matrix SW (Surface Water) - GW (Ground Water) - WW (Waste Water) - DW (Drinking Water) • SL (Sludge) • SO (Soil) OL (Oil) Other (Specify) <br />JQA�J �vl�c�5 �i G 43 .N62FZi� <br />Please refer to ACZ's terms & conditions located on the reverse side of this COC. <br />RELINQUiSHEDD• D• <br />V .-P. S <br />LQt�F(�11 White - Return with sample. Yellow - Retain for your records. Page 14 of 14 <br />