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Chain of Custody Form l^� COLorQdo <br /> Rejort To Information Bill To Information(If different from epW to) project Name 1 Anal dcd <br /> LABORATORIES,INC, <br /> Co pany Name: Company Name: 1` "1 <br /> nA�� Briehtoa Lab <br /> Car tact Name: w'+� Contact Name: 240 South Main Street <br /> 14 Brighton,CO 806Mi <br /> Address: �h , j� _• ``�}` Address: Task Number(Lab Use Oniy) !Akewood Lab <br /> CAST ask NO. 12860 W.Cedar Dr,Suite 100A <br /> bW 150826040 Lakewood CO 80228 <br /> wVAr Phone:303-659-2313 <br /> C' State e0zip city State Zip Fax:303-659-2315 <br /> EMN <br /> Phone: 7-26 Fax T7 Z.SJ- Phone: Fax: www.c-oloradofab.com <br /> Email: In �.Cy'1 Email: Sample Disp.Date(LabUse Only) <br /> Savipler Name: PO No.: <br /> Sam le Matrix Select One On T <br /> Waste Water ❑ Soil ❑ Punt Tissue ❑ p <br /> G ound Water❑ Sludge ❑ Other ❑ 8 <br /> U <br /> Sn ace Water Compost ❑ 4i <br /> � U <br /> Da a Time Sample ID z o` v <br /> I , W�5 L-Tc- <br /> Instrnctioas: CIS Info: Seals Premc Yes No <br /> Deliver We tq6tkxd CIS Cha e❑ Teo�;'1 "ce Simok Pre&Yes No <br /> Reli uu Date/Time: RWived By: Date/Tlme: Relinquis By: Date/Time: Received By: Dat ime: <br />