Laserfiche WebLink
Chain of Custody Form ^� Colorado <br /> Report To Information Bill To Information(If different from report to) Project Name •Analytical <br /> w�/► / ,/ LABORATORIES, INC. <br /> Company Name: I�t`�'� C � Company Name: �t C�r�l St7 �l ' Brighton Lab <br /> Contact Name: K�J Contact Name: 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: a Address: Task Number(Lab Use Only) Lakewood Lab <br /> 12860 W.Cedar Dr,Suite 100A <br /> CAL Task No. Lakewood CO 80228 <br /> 170829062 <br /> City I t Statg`' Zip .� <br /> EMN <br /> �►�'�(Ei city State Zip Phone:303-659-2313 <br /> A Fax:303-659-2315 <br /> Phone: +� �1 Fax: Phone: Fax: www.coloradolab.com <br /> Email: r-/Li I i' 1U �If•t�L Cx7^F 4 1 t-^ Email: Sample Disp.Date(LabUse Only) <br /> Sampler Name: •i,5 PO No.: <br /> Sam le Matrix Select One Onl <br /> Waste Water ❑ Soil ❑ Plant Tissue ❑ W. <br /> �j M <br /> Ground Water❑ Sludge ❑ Other ❑ •J t° <br /> ,R a) <br /> Surface Water + Compost ❑ 46 U ;, a <br /> a <br /> �. <br /> Date Time Sample ID z v <br /> Instructions: C/S Info: Seals PresentYes❑No❑ <br /> j Q <br /> Deliver Vs.• C/S Cha e❑ Tem "CAce Sample Pres.v'as❑ No ❑ <br /> Relinquish Date/Time: Rpf eived Dat i nquished By: Date/Time: Received By: l !me: <br />