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Chain of Custody Form ^� Colorado <br /> Report To Information Bill To Information(If different from report to) Project Name 1 Analytical <br /> c� M y LABORATORIES, INC <br /> Company Name:_' G�� �i It Company Name: t rOA,-;( ! t/� <br /> Brighton Lab <br /> Contact Name: f J � Lv I pTl.v4, Contact Name: 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: r S a �y �} Address: Task Number(Lab Use Only) Lakewood Lab <br /> )5(,) <br /> 4 1* r-AL Task No. 12860 W.Cedar Dr,Suite 100A <br /> f 170725100 Lakewood CO 80228 <br /> City D6*)V� Stab'G) Zip �� cityState ZipPhone:3-659 2315 3 <br /> �/ Fax:303-659-2315 <br /> Phone: Fax:D,-D14y Fax: Phone: Fax: EMN <br /> .I www.coloradolab.com <br /> Email: ry�✓l IMA �-IBS I CIS;�:Wl Email: Sample Disp.Date(LabUse Only) <br /> Sam ler Name: [')QVi 61-040-Allf PO No.: <br /> Sam le Matrix Select One Onf .. <br /> T <br /> Waste Water ❑ Soil ❑ Plant Tissue ❑ 8 M <br /> Ground Water,❑/ Sludge ❑ Other ❑ j M <br /> Surface Watef Compost ❑ v 8 VIM <br /> rl o V 0 a <br /> Date Time Sample ID z 0 o u <br /> nInstructions: Us Us Info: Seals Present Yes❑No <br /> Deliver"' I r C/S Cba e❑ TX '22OCAce Sample Prey ❑ No <br /> Relin uish Date/Time: Received By: late/Time: nquished By: Date/Time: Received By: I me: <br />