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�1�lfiti� 6G's�K r <br /> CHAIN-OF-CUSTODY AND ANALYSIS REQUEST <br /> Analytical (970)247-4220 service@greenanalyticai.com or dzufelt@greenanaiytical corn <br /> i .,I,o ra3xo I'll <br /> ,• Fax: (970)247-4227 75 Suttle St Durango,CO 81303 �p <br /> Company or Client: ,L ,v _ Rill to(if different): ANALYSIS REQUEST a <br /> Address: 3 y ? P.O.#: I (o <br /> City: State: zip: Ft�l�r Company: Ll <br /> Phone#: j Q�,'_— &'rj Z- ? Attn: <br /> Contact Person: o �'(L. Address: <br /> Email Report to: os f Z `cow ��+��'�• C�11�. City: <br /> Project Name(o tional): l7/ nn0 <br /> CQi(6t State: Zi : <br /> Phone#: <br /> Sampler Name(Print): Email: V <br /> Collected Matrix(crock one) #of containers <br /> C W • <br /> Lu W Cr <br /> fill <br /> For Lab Use Sample Name or Location o w 3 <br /> Z <br /> Q W(� 52 Z <br /> C1 J Z UJ <br /> ( , <br /> Date Time � y ?� a C.y O z i _ <br /> 7, i <br /> PLEASE NOTE <br /> OT A AL lability and d iint's e.chrswe remedy for any claim ansrng whether basal in contract or ton.shall be knitted b the m aid mount p by the client for the analyses.AM claims incluclin0 those la negligence and any oM.,cause wWlsnover shall be deemed waived unless nestle in writing and-ver <br /> by GAL wRhi 0 des after can 1t N no*vent shall GAL be liable for incidental or consequental damages,in.l.d.g without fundaybon.business Interruptions.loss of use.of loss of prorlb tmunetl by client,es subsidiaries.afruiates or successors arising out of or related to the performance of son ices hereunder <br /> GAL.r altlle5 el wheth dh K Weed Uron any of the rtt w-stated rBAsons or otherwKe. <br /> e I i as011-7 Receive Bv: ADDITIONAL REMARKS: RCDort to State. ((irc c l <br /> 7D-d' ,J'-,P P,A J//11--fl- Yts No <br /> Relin d Bv: W"i Date: r Received Bv: <br /> Time: <br /> Relinquished Bv: Date: Received Bv: <br /> Time: —�� I—� <br /> - <br /> Relinquished Bv: Date: Received_ By j6Le"` <br /> Time: 2—,& 3 C � <br /> �•mpera tin f' ,,cipt: CHECKE <br /> t GAL cannot always accept verbal changes.Please fax or email written change requests. <br /> Chain of Custody must be signed in"Reliquished By:-as an acceptance of services and all applicable charges. Just aick Printing Form#17-0301 <br />