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ACZ Laboratories, Inc. �� �02255 <br /> 2773 Downhill Drive Steamboat Springs, CO 80487 (800)334-5�93 <br /> • • <br /> Name: e � eri" Address: �ID� Ma'M <br /> Com an : xw tgpz vt C� 1 L 1 <br /> E-mail: nla b �!� f SaC a hone: <br /> Copy of Report to: <br /> Name: / e P (rm� E-mail: � OC yr VKP►� <br /> Company: Tell hone: .S CM u/�7 <br /> Invoice to: <br /> Name: Address: <br /> Compan : <br /> E-mail: Telephone: <br /> If sample(s)received past holding time(HT),or if insufficient HT remains to complete YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO <br /> "NO"Own ACZ will snMast'lion ter furdwr Ihaftchm.M nefter'YES"ner"NO"is Indicated,ACZ wit p—ed with the requesbd snsysss,oven N NT Is esp ,and data w•6o gwlirwd <br /> Are samples for SDWA Compliance Monitoring? Yes No <br /> If yes,please include stateforms.Results will be reported to PQL for Colorado. <br /> Sampler's Name:Al, QGf,1 sampler's Site Information State C� Zlp code rJ Time Zone <br /> 4 sliest to th•aulhentlalty and valiiy of this sarnpM.1 unMraland that NdentNnalty Inklabatine the dwstdatencodtion or <br /> 'Sampler's Signature:011" fampwind with the srnplo In.nyway,Is considered fraud and punisholis by&nds Law. <br /> PROJECT •• • <br /> Quote#: 7-- n <br /> PO#: <br /> 49 <br /> Reporting state for compliance testing: _ <br /> 0 <br /> Check box d samples include NRC licensed material? o ,a <br /> F+1 <br /> Matrix SW(Surface Water)•GW(Ground Water)-WW(Waste Water) DW(Drinking Water)•SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> O <br /> r.t <br /> �S} <br /> O <br /> aeae�.,y <br /> �r <br /> Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> RELINQUISHED ■• • L DATEJIME <br /> !fl I(/- — I <br /> If <br /> L ��Q bb�59 White-Return with sample. Yellow-Retain for your records. Page 33 of 33 <br />