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Chain of Custody Form R*Eoloradp <br /> Report To Information Bill To Information(If different from report to) Project Name Anal tical <br /> "'Labaratorles, Inc. <br /> Company Name: NU25� Company Name: T-f?Am5'f M 1/C <br /> Brighton Lab <br /> Contact Name:PfWL KOS Contact Name: ���2 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: � .{ Address: Task Number(Lab Use Only) Lakewood Lab <br /> 12860 W. Cedar Dr,Suite 100A <br /> CAL Task No. Lakewood 80228 <br /> 170810107 CO' <br /> lJ "'�`"L Statue Zi '2 l t(, City State_ Zip Phone:3 -2313 <br /> City P P Fax:303-659-2659-2315 <br /> EMN <br /> Phone: 3cr3 —7a;,,oi611Fax: Phone: Fax: www.coloradolab.com <br /> Email: P 144s IZ, U.W^ Email: Disposal Date(Lab Use Only) <br /> Sample Collector: 4 PO No.: <br /> I'I,i°iY.iN,ll;l, 'a1„�" t:° ;�I k..;l!:a�•:Ijk;p"�.a: tl ,i' ii� ;i q �' ;.• <br /> T <br /> Waste Water ❑ Soil ❑ Plant Tissue ❑ O ,a <br /> Ground Watef'� Sludge El Other ❑ �' c <br /> Surface Water ❑ Compost El o "� <br /> k.l ' LICs;I .:h, x l Ii Z co o U tiJ a <br /> r, yl� 'P ,' <br /> V IV/f7 i 30 LTC- ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0 E ❑ ❑ 0 E 0 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ E E El El E ❑ ❑ ❑ ❑ ❑ 11 ❑ <br /> El El E ❑ ❑ El ❑ ❑ 0 F E 0 01 E ❑ ❑ ❑ ❑ <br /> Ell El El Q Ell Q ❑ ❑ ❑ E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El I E E El ❑ EJ ❑ ❑ ❑ ❑ ❑ ❑ Ell ❑ ❑ <br /> ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ell ❑ ❑ Ell ❑ ❑ Ell Ell <br /> El El Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ <br /> Instructions: C/S Info: seals Present Yes No <br /> �co It N1Pty and Tro-Vat <br /> Deliver Via!V -4P-� C/S Charae❑ I Temp. �DC/Ice Sample Pres.Yes❑ No <br /> inquished By: Date/Time: Received By: Date/Time: I Relinquished By: Date/Time: Received By: Date/Time: <br />