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CHAIN-OF-CUSTODY AND ANALYSIS REQUEST <br /> (4MLA tiCal (970)247-4220 service@greenanalytical.com or dzufeit@greenanalytical com <br /> Fax:(970)247-4227 75 Suttle St Durango,CO 81303 <br /> Company or Client: 5un7 Se (Yl r 7 17 Bill to(if different): ANALYSIS REQUEST <br /> Address: 3? Z!v r`l Sfa,fif P tt P.O.44. <br /> City: S State: C0 Zip:---_O 3 company: Z Inf�O�'�o�Ct e <br /> Phone#: -7 Z 0 nun: /'-t <br /> Contact Person: /4-7 °U rC)f r?o 6i Address: <br /> Email Report to: r j!q no-6—OS 00 T� i o e,I>rd r0 Clty: <br /> Project Name(opLfonal): 30Y- 7 10 d 925 Q,/'C., 4), Ar,f- Stale: 'Zip: � <br /> S l,'na.tS% G>cl,am 11, ll�CtlmS , C'o✓n SAS Phone4#: <br /> Sampler Name(Print): Email: <br /> Collected Matrix(check one) #of containers <br /> W <br /> w w W ', F- " Z <br /> t- LU <br /> For Lab Use Sample Name or Location z a W I Z d <br /> _ Date Time O N o a o� o O z = !_ =1 O O <br /> -D1 f 3 Pn L 2 ' I t x <br /> y i -7 y:aye - - <br /> ----- 0 z� 7 - 3 z f ( 3 y6 Pm — <br /> JE6•zL 17 - S- (O Z 1 1 D�- — - ---- - <br /> - �, 2-1 17 - Z <br /> 2/l -7 - - <br /> --- b t, z-1 -7 - 9 to z t /7 —-- <br /> - <br /> PLEASE NOTE: ' tiatil and 1's ere medy for any claim arising whether based in contract or toil,shall be limited to the amount paid by the client for the analyses All claims including those for negligence and any other cause whatsoever shall bo deemed walled unless made m writing and recorver <br /> by GAL wilhln days fler ca n In no event shall GAL be liable for Incidental or consequentat damages,including without lim lahon,business interruptions,loss of use,or loss of profits Incurred by client its subsidiaries,affiliates or successors ansmg out of or related to the performance of semces hereunder <br /> GAL,m rd.,s helh Ich ciatm Is based u an of the above stntod m sons or otherwise <br /> e in Is Dat= Kec 3v: ADurrlor`IAL REMARKS l:euort Lo SL.+let(Cwde) <br /> Time, v Ycs IN <br /> R• heel Bv: Datt Re c1 Bv: <br /> `m�$a�' � <br /> �' rintt•:OQ S 66211� -S aS ara°G> c�a5 d J� zz <br /> Re tnuuished B r Date I ce d Bv: <br /> Teri nnui.shed Bv: Wit, Received Bv: <br /> Tintr � ���• <br /> Prn,llcrnturea[rc•trtfrt: CIILCKfiDt21' <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. dust CIIck Pnnung Form#17-0301 <br />