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Ar"Z Laboratories, Inc.• <br />2773 Douvnh!!! Drive Steamboat Springs, CO 80487 (800) 334-54L93 <br />Name: Address: <br />Com an : *C <br />E-mail: Telephone: % <br />1 Copy ot Report to: <br />Name: E-mail: <br />Company: Telephone: <br />Invoice to� <br />Name: Address: <br />Company: <br />E-mail: Telephone: <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 />ill"NO" then ACZ will t Uecl client ler further butruelbn. If rwMwr "Y[Y ner "NO' is hubessed. ACZ wig prx.ed with the requested anNyus, wen If MT la.api and data wrh be ii"Ofied <br />Are samples for SDWA Compliance Monitoring? Yes No <br />If yes, please include state forms. Results will be reported to PQL for Colorado. <br />Sampler's Name: XIAIAAI Sampler's Site Information State Zip code Time Zone <br />'I attest to UM autMnbcity and validity of this sample I understand that intentionally mislshelinp the timNdeta/kmadan or <br />"Sampler's Signature: tamWing with the ar ple M anyway, a oonsidenad fraud and pwishable by 8tata Law. <br />PROJECT INFORMATION <br />Quote <br />d <br />PO#: ¢S( d t^ <br />Reporting state for compliance testing: C <br />Check box if samples include NRC licensed material? <br />7'� <br />fi V} 1, .2 <br />Matrix SW (Surface Water) GW (Ground Water) WW (Waste Water) DW (Drinking Water) - SL (Sludge) - SO (Soil) OL (Oil) Other (Specify) <br />�pet°a ✓s A be -jr,� !s --e /-.4 le-. /y1� )t f- �� v 41 efP' /-,iWesl� <br />aAt-L ryQeZC. C3St�'xrS). Zv f WG.c IL � GlcVc k J1e1 Sz< <br />VS' ,w 114 eve✓ Or? -I �t f, er yev writ i L cover <br />d��iz. a� <br />� 7`rA i.. tad � v f- 2 rr►c,-y 6� /►, dr -e re,Q/e 56-111 hi X �. <br />lease refer to ACZ's terms & conditions located off the reverse side of this COC. Iw✓r h S%laac/ <br />REUNQUISHED •• • D• <br />FkFAAD650.06.14 14 White - Return with sample. Yellow - Retain for your records. �'� <br />"1o� <br />71Qff- <br />