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BMW <br /> Chain of Custody & Analytical Request Record <br /> Trust out"le.Trust our DM. www.energvlab.com Page of <br /> kccount Information (Silting information) Report Information (rf different than Account Information) Comments <br /> :ompanyMameAp-od �vLx ' Company/Name t Fvti[ <�GSG Cpr' 44c— <br /> :ontact S Contact k I ? s�17 <br /> ) t0. k �- ��/ W C L'n�` <br /> 3 J <br /> 'hone 0 3 ql/ q—1�/ Phone 3J J O <br /> hailing Address - LY I41_ Mailing Address D S J I <br /> ;ity,State,Zip City,State,Zip dCo g <br /> :mail a Email �� <br /> teceive Invoice []Hard Copy ❑Email Receive Report ❑Hard Copy ❑Email Receive Report MrardCopy VGail <br /> 'urchase Order Quote Bottle Order Special Report/Formats: <br /> ❑LEVEL IV ❑NELAC ❑EDDlEDT(contactteboratory) ❑Other <br /> 2ro'ect Information Matrix Codes Analysis Requested <br /> Iroject Name,PWSID,Permit,etc. ` A Air All turnaround times are <br /> W t w- water standard unless marked as <br /> /1 <br /> ;ampler Name MLk <br /> �t{ � Sampler Phone S- Soils/ 4' RUSH. <br /> \" \\\��r a l solids Energy Laboratories <br /> ;ample Origin State EPA/State Compliance ❑Yes ❑No V- Vegeten� MUST be contacted prior to <br /> 1RANIUM MINING CLIENTS MUST indicate sample type. a Bioassay RUSH sample submittal for <br /> 7 NOT Source or Byproduct Material 0- Other t charges and scheduling— <br /> SourceiProcessed Ore(Ground or Refined)"CALL BEFORE SENDING DW- vvekn9 See Instructions Page <br /> 1 1le.(2)Byproduct Material(Can ONLY be Submitted to ELI Casper Location) Q <br /> Sample Identification Collection a,mne,�r Matrix 3 RUSH `a <br /> Cod- <br /> (Nam, rn <br /> (Name,location,interval,etc.) Date Time Containers /see Above TAT ^ <br /> IP - vx!� 0 4 alo C ICgl Ock c> <br /> - -k9 09yo I1 <br /> t n fo 25-t� 10 KO �J <br /> a Ah CP <br /> r <br /> ID <br /> Custody elinqu hed by(print) Daterrime Signature Received by(print) DateiTime Signature <br /> iecord MUST <br /> be signed Relinquished by(print) Date/Time Signature Ric L ( $t VIVA <br /> TORY USE ONLM': �.. <br /> Shipped By Cooler ID(s) Custody Seals Intact Receipt Temp Temp Blank On Ice ayment Type Amount Receipt Number(cestilcheck onM <br /> Y N C B Y N °C Y N Y N CC Cash Check $ <br /> L.....a.................r...--- ,...--fine 1..ti.....a...,.,.. 1— mw ha—h—d. t—1+r Min—r rtiflad lahnrWnriac in nrrlor fn complete the annivsiS reauested. <br />