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CHAIN-OF-CUSTODY AND ANALYSIS REQUEST <br /> CO <br /> N <br /> (4AwA <br /> ytieaLl <br /> t (970)247-4220 service@greenanalyttcal com or dzufelt@greenanal deal com 0 <br /> „r t r y <br /> Fax:(970)247-4227 75 Suttle St Durango,CO 81303 j <br /> Company or Client: _577t Se 7, /l Aq i-C Bill to(if different): ANALYSIS REQUEST � <br /> Address: ,3 9 Z.4 1\j Sra l e N v� c i0 1Z P.0.it- <br /> City• S Pc( CO p; O i > 9 2 �n1rOr �(t�tE'cl �-` <br /> _----- 4l !hiss —_ State: Zt � 3� Coin tau• <br /> Ll <br /> Phone#: _,Z O_ Attn.Contact Person: /),jail Address. <br /> Email Report to: 6"OrOe r061 0 00 <br /> — 2 <br /> ('0 Uty. <br /> T <br /> Project Natue(upttonal) <br /> State- Ztp: --- -- <br /> J r 4 <br /> rJQ tS'-� �' C7 r(.c/I7G�h vt/-��1'Ctl�/�'JS C:'U✓�? `��S_ Phone t{------ <br /> Sampler Name(Print): limad: <br /> __Collected Matrix(check one) — #of containers <br /> w Q Lu .Q <br /> For Lib Use Sample Name or Location o 0 W Z r. 1 •4 G, <br /> a <br /> Date Time � y a 5 p O`z S i = 0 0 <br /> - - - <br /> ��' 3•q'� �17 - 2.— 1 l x <br /> - -�Z- Co z 1 17 - z z► y:s� - - - <br /> --- 7 - 3 -- ell <br /> Z 1 ( 3' 16 Prn j — <br /> 7 t, 12.1 It T5 *,0"1 OP <br /> Jf 6•ZZ -- 2l / <br /> Mi- <br /> b� 2-/ -! - to z/ /7 - -- <br /> 010 zl <br /> PLEASE NOTE: pe-kty and 's ezdusrve nenady tar any claim arising whether based in contract or ton,shag be timted to the amount pad by the chant for the analyses All claims including those far negligence and any other cause whatsoever shall be deemed waived unless made in writing and receiver <br /> by GAL wMm days ner co In no event <br /> shag GAL be liable for mcdPntal or consequental damages,lodaWng without Ymaaaon,business atlerrupbore,loss of use,or loss or profaa incurred M chant ga subsidiaries,affiliates or successors artvng out of or related to the performance of services herounder <br /> by GAL r ern ch clam s based u n a of the above stated reasons or otherwise <br /> e n IS D�t�� 2e( 3v: iE.Lit::i- annrrutNal.rl:nlaRl w of RPp01't to 1l.hle 1t-1rC t') <br /> Time /�L,�� /y�/� <br /> /� 1'rti Nu <br /> R Ited 13v. Doty Re d Kv:' 170 sa,n o <br /> m0. 'Flow, u'S- b62!!� -S oS ata uoos ulna JE C zz, z <br /> Rc fnututittrd! r - - D.vr f 'cc d Bv: <br /> ----------------------- <br /> Reluuthutihed Rr: Itato Received Bv: -- — <br /> ! 'I'rmperatulc<htrrrrtpt. CN(ifhEttl31' <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 Click Pnnl Form#17M01 <br />