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ACZ Laboratories, Inc. �� <br />2773 Downhill Drive Steamboat Springs, CO 80487, (800) 334-541 <br />.. .. <br />Name: (� P = �r✓ I� <br />Address: 115 k 12414 -1A1'5 -r., <br />Company: t'__%U0RG FLtLS <br />E-mail: C 1 .� �, ;; <br />Telepho e: 111 C% ZY 9' l0 3 -75 <br />Copy of Report <br />Name: <br />E-mail: <br />Company: <br />Telephone: <br />Invoice • <br />Name: SAM 4- Address: <br />Company: I 'I <br />hon: <br />E-mail: l.: Tele p ' <br />If sample(s) received past holding time (Ill or if insufficient HT remains to c mplete YES <br />analysis before expiration, shall ACZ proceed with requested short HT analysles? NO <br />If "NO" then ACZ will contact client for further instruction. If neither "YES" nor "NO" is indicated, ACZ (III proceed with the requested analyses, even if HT is expired, and data will be qualified <br />Are samples for SDWA Compliance Monitoring?' I I Yes No <br />If yes, please include; state forms. Results will be reported to Il for Colorad . <br />Sampler's Name: 117% �ampleil Site Information I State Zip code T/ -2Z6 Time Zone <br />attest to the authenticity and validity f this sample. I understand that intentionally mislabeling the time/dale/lcation or <br />I*Sampier's Signature: II i tampering with the sample in anyway, i considered fraud and punishable by State Law. <br />PROJECT• • <br />Quote #: I' III L <br />Po#: Cv►�.(--fit i�U�L� � 9� f �'S' �� �' III <br />Reporting state for compliance testing: III o <br />U <br />Check box if samples include NRC licensed material? I II c <br />rE :� � 1 ac3 y-��-/S ea P IW � Cit,/ IlN lrrr <br />III <br />� <br />I <br />III <br />� <br />I,. <br />III <br />I <br />II I: <br />III <br />Matrix SW (Surfaced Water) GW (Ground Water) WW (Waste Water)( DEW (Drinking W <br />REMARKS <br />ter) SL (Sill dge) SO (Soil) OL (Oil) Other (Specify) <br />Aj i II � <br />Z G <br />f' ti 7. ? <br />(Please refer to ACZ's terms & conditions located on <br />RELINQUISHED <br />t e reversel <br />side of this COC. <br />�$�➢ q Zii}1�31 White - Return wi sample. lelil w - Retain for your records. Page 10 of 14 <br />