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Chain of C-% ,y Form 4!��N CotorQ <br /> Report To Information Bill To Information(If different from report to) Project Name Anabjd= <br /> LABORATORIES.INC, <br /> Company Name: 1 W► W Company Name: ,` ` ' <br /> 1 Q Brighton Lab <br /> Co tact Name: w Contact Name: 240 South Main Street <br /> Brighton,CO 8060I <br /> Ad ress: ��SL) � (ten. Address: Task Number(Lab Use Only) Lakewood Lab <br /> JV 12.860 W.Cedar Dr,Suite 100A <br /> CAL Task Mm <br /> % � � 150826040 Lakewood CO 80228 <br /> Ci State eoZip city State Zip Phone:303-659-2313 <br /> Fax:303-09-2315 <br /> EMN <br /> Pbo e• 7 Fax: �72 2 ZSLOPhone: Fax: WwW.coloradolab.com <br /> Em il: (� (OR� Ci Email: Sample Disp.Date(LabUse Only) <br /> Sa Pier Name: PO No.: <br /> Sam le Matrix Select One On <br /> T <br /> Waste Water ❑ Soil ❑ Plant Tissue ❑ p <br /> G ound Water❑ Sludge ❑ Other ❑ p <br /> Su ace Water Compost ❑ w o <br /> o E <br /> U <br /> Da a I Time Sample ID z o U <br /> R <br /> ons: CIS Info: Seals Present Yet No <br /> Deliver Vint CA Charze❑ Teaa P,! *CA- SmanOW Pres.Yes Of No <br /> Reli uis DatelTime: R ,ived By: Date/Time: Relinquish By: Date/Time: Received By: Dat i ne: <br /> 1?bIJ, Ms I �Utrs t 5�'S <br />