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Chain of Custody Form <br /> Report To Information Bill To Information(If different from report to) Project Name qk�Colorado Analytical <br /> "'Laboratories, Inc. <br /> Company Name: Ab44'46rlZ,IAA)S,7 IVIX Company Name: TiQ Alsir xnx <br /> Brighton Lab <br /> Contact Name:_A�AZ—A7,za- Contact Name: HAA PQ. S4/��;3 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: Address: Task Number(Lab Use Only) Lakewood Lab <br /> 950 Cfl,312.Q Y ST. s,,+!�S�o CAL Task No. 12860 W.Cedar Dr,Suite 100A <br /> 170810007 Lakewood CO 80228 <br /> City Z)9UMgF— State4 O Zip 00246 City State_ Zip Phone: 303-659-2313 <br /> Fax: 303-659-2315 <br /> EMN <br /> Phone:-103-T -Q/64V Fax: Phone: Fax: www.coloradolab.com <br /> Email: Akqe, i Q✓0r%odS`CM COAT Email: Disposal Date(Lab Use Only) <br /> Sample Collector: PO No.: <br /> ,,;I', I ,ji .i Il,� y?iy7Vi ilil"Ili'bi.l.l ,li,ili?Jll;ih'i,ilfuN�ll�ln9111j1hj,'nM1 ,liu'llll� 11I .Il,l�ii�a: _ <br /> Waste Water ElSoil ElPlant Tissue Elo <br /> Ground Water[v]� Sludge ❑ Other ❑ o v Z w <br /> = v — o <br /> Surface Water ❑ Compost ❑ � U o E 4 <br /> 0 <br /> Dote z C7 o�I' ~ v a <br /> C� <br /> 811 %7 i3.:20 L7-C-G442 -6Y2 ❑ ❑ El ❑ ElEl ❑ ❑ ❑ El1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El E <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ El ❑ <br /> ❑ ❑ El Ell ❑ E ❑ ❑ ❑ El JE11 El ❑ ❑ ❑ ❑ Ell <br /> El El ❑ ❑ ❑ El E ❑ ❑ ❑ 0 El ❑ Ell ❑ ❑ ❑ <br /> El El E ❑ E 0 ❑ El El El ❑ <br /> Instructions: / C/S Info: Seals Present Yes cl No <br /> Deliver Via:�� 1 Os Cha e❑ 1'em 'C/Ice Same <br /> Pres.Yes❑ No <br /> Rel' quisho"y: Date/Time: Receiv d B Date/Time: Relin is ed By: Date/Time: Received By: n-*a/Time: <br /> ��' r7 tGoG 91911T loot ® 8 �o 17 � t'Sp I V� .i-1 1, t-1 <br />