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Chain of Custody Form , jg o ,C e)'5 <br /> Report To Information Bill To Information(If different from report to) Project Name • `Colorado Analytical <br /> Ldbur dtorit s, 1flL. <br /> Company Name:Colorado Analytical Company Name:Same 180912021 <br /> Brighton Lab <br /> Contact Name:Stuart Nielson Contact Name: Mill Iron 2354-01 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: Address: Task Number(Lab Use Only) Lakewood Lab <br /> 240 S.Main St 12860 W.Cedar Dr,Suite 100A <br /> Lakewood CO 80228 <br /> Phone:303-659-2313 <br /> City Brighton State CO Zip80601 City State_ Zip Fax:303-659-2315 <br /> Phone:303-659-2313 Fax:303-659-2315 Phone: Fax: www.coloradolab.com <br /> Email:stuartnielson@coloradolab.com Email:• Disposal Date(Lab Use Only) <br /> Sample Collector:Thad Miller PO No.: <br /> Sample Matrix(Select One Only) . T <br /> Waste Water El Soil ❑ Plant Tissue ❑ O a' <br /> 5 <br /> Ground Water® Sludge 0 Other CI a <br /> O <br /> 0. <br /> Surface Water I:=1 Compost CI .o <br /> - -= R. h <br /> o 0 <br /> U E o <br /> Date Time Sample ID z c) o U o <br /> 9/12/01 0920 180912021-01D MW-3 I ® ❑ ® ❑ ❑ El ❑ ❑ El El ❑ El ❑ El El El El ❑ <br /> O 00000000000 ❑ 0 ❑ ❑ 00 <br /> O ❑ 0000000000000000 <br /> O ❑ 0 ❑ 0 ❑ ❑ ❑ 0 ❑ 00000 ❑ ❑ ❑ <br /> O 0000 ❑ 00 ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ 0 ❑ <br /> . ❑ 00 ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> O 1::1000. 0 ❑ 00000 ❑ 001:10 ❑ <br /> O ❑ 0000000 ❑ 000 ❑ 000 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Instructions:Send to HazenC/S Info: Seals Present Yes 0 No 0 <br /> y ! f7 Z. 1,911(p .^ `�7c1�t(� 73li'( <br /> 5401+LC L (I +445 Si4dltic€ /r'r'� <br /> p= S Deliver Via: C/S Charge❑ Temp. °C/Ice Sample Pres.Yes❑ No 0 _ <br /> Relinquished By: Datri e Received B14. 000E1000EI Relinquished By: Date/Time: Received By: Date/Time: <br /> ('-if,.\ 44:7y_dzirv_____ crt.t/S , <br /> page 5 of 5 <br />