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CHAIN-OF-CUSTODY AND ANALYSIS REQUEST <br /> CM <br /> mA N <br /> Ar talytlCa) (970)247-4220 service@greenanalytical corn or dzufeit@greenanalY deal corn O <br /> t .,1,, ,r .,t „il, • <br /> Fax:(970)247-4227 75 Suttle St Durango,CO 81303 naT <br /> 'Company or Client: 77 se 01, AI A 4_i- Hill to(i1 different). ANALYSIS REQUEST <br /> ------------ -- <br /> Address: 3 9 Z/O fV Sra.f e 9 l0 3L 11,0.t.' - <br /> City: _-- _S Pc/4 j�Q State: C'� Zip: D / 3 J niiirorj:JOro�te 7 <br /> Phone#: -- O_:_�a .2 S 37 - —---- Attn. APUt' <br /> Contact Person: ��PUn /�u6, nSorb Address: -t- <br /> --- - t- -- <br /> Email Report to: (?(I YGc�P� . <'o Clty: <br /> - -------- - -- -- --- -- -- <br /> I'luit•cl halne(opUonal) 3C3 - 7�(� �q L j J �'� f t 1' SOW' 7.11), d' <br /> --------- ----- <br /> ---------- <br /> 5 1,'�eetS c�1y��m� cal r�-�l�a�mS , tom_ s�S Phone4_ ---- _---- , <br /> Sampler Name(Print): 1:111,111: <br /> —Collected Matrix(check one) _ #of containers <br /> cc w <br /> w tw- M Fw <br /> a I, 3 <br /> For Lab Use Sample Name or Location w a 0 s a c <br /> Date Time W 0 cn a c a cn 0 1Y f-. o z v L <br /> 0 S� 0 IS_O" z_= x = O <br /> z 1-� - �1_� 1 _�,3 - 2. z X <br /> Z -0�o)_11 7 - <br /> -off 7 <br /> k� - -- — <br /> 3 Zi I 3�yo+'m <br /> 04- b(az/ 17 - ! 5 %0�{PIdJ <br /> Jf6•Zt d(� 2I I ?_- S12,1 1 <br /> 1 <br /> ---- ------- <br /> a5- <br /> - <br /> b(o 2/ 7 - (v ,Z/ /7 <br /> PLEASE NOTE: sehihty and 's exclusroe—ady for any cairn ansing wWher based m contractor tort,shall tm landed to the amount pad by the client for the anayses Alt clams including those for negligame and any other cause whatsoever shall be deemed waived unless made In wnnng and receroer <br /> by GAL vnih. tlays liar co In no event shall GAL.bade for incidental or consequental damages,Indudi g without limitation,business interruptions,loss of use,or loss of profits incurred try client.its subsidiaries,affiliates or successors arising out of or related to the performance of serwcos heroundei <br /> GAL r eth ch claim s based u n an of the abave staled reasons or othervrreo <br /> ROM is at't RCC 3v: ADI)ITIoNAt.RKPIARKS Repo 1C Report do state. n-c e) <br /> a tihed 13v. "" + Re EtsV:- - �Io satnpCe. r <br /> k�`ma o�`� rll,t, b62J1� -S aS ateA 1tuOS d d� zz <br /> aqua _ � <br /> Re Iruultihrci Iv-- -- -- flan, f tic-e d Rv. - — --- <br /> I <br /> '1'lulr <br /> I Vi (0- <br /> Received Rv: <br /> Ilnti, , <br /> 'I',•rtlpelatulvat CHUCKED BY <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 Click Pnnbng Form 1$17-0301 <br />