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Chaim of )dy Form fk) Color ► <br /> R port sibmation Bill To Inrormation(ifdiir'ertm from resort to) Project Name AnoWL,..A <br /> y� 1 LABORATORIES, INC <br /> l <br /> C mpsay Name: ' ori�����f Coespsny Name: <br /> Brieh;on Lab <br /> C ritsctName AnWOL Contact Names 240 South Main Street <br /> Migbton,CO M601 <br /> A Tess: Address: Task Number(Lab Use Only) l,akewaod 1Ab <br /> 12860 W.Cedar Dr,Suite IUOA <br /> eQQ 150616081 Lakewood CO SIMS <br /> -659-2313 <br /> �Ycwrs.1*- State tbzip 302,q`0 Ci state Zip RNt Phone:303 Fax:303-65959-2315 <br /> P one: P61i Paz: pn 661D Phone: Fax: www.eoloradolab.com <br /> ll all: f r Smag: Sampk Mp,Date(LabUsc Only) <br /> SR6 pier Name' PO Na.: <br /> Sample Matri: Select One On <br /> aste Water ❑ Soil ❑ Plant Tissue ❑ 8 <br /> round Water❑ Sludge ❑ Other ❑ p <br /> S rface Water, Compost ❑ o <br /> D�ft <br /> +tTime Sample 1D z° v h U LU <br /> kl L--T C— '" <br /> Inst actions' CIS Into: Seals Preaeal Yes No <br /> Deliver Vn: C/5Ck3MQ Tom/'CJ4 UmwePntYmQ No <br /> Ret' quished: Date/Time: R y: Relinquished By: Date/Time: Received By:I DstefPhae: <br />