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Chain of Custody Formill ` <br /> Report To Information Bill To Information(If different from report to) Project Name • •'1 Colorado Ar1iI tical <br /> -Laboratories, Inc. <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 CQQ 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 a@,coloradolab.com Email: Disposal Date(Lab Use Only) <br /> Sample Collector:Thad Miller PO No.: <br /> Ciaoaoy51 <br /> Waste Water 0 Soil 0 Plant Tissue 0o <br /> C d <br /> Tr <br /> Ground Water El Sludge 0 Other °° Y <br /> Surface Water 0 Compost 0 <c?.. <br /> ..= a o <br /> z (. o C cg <br /> 9/12/18 0920 180921021-01 MW-3 3 ® ❑ Ek ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ • <br /> D ❑ oq❑ ❑ gg0O ❑ Do❑ ❑ D ❑ o <br /> ❑ ❑ ❑ d ❑ ❑ ❑ ❑ ❑ a0 ❑ ad ❑ 000 <br /> o ❑ o❑ ❑ ❑ gg000qq❑ ❑ oqo <br /> • D ❑ ❑ D ❑ ❑ ❑ q❑ o ❑ ❑ ❑ ❑ ❑ q <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o❑ o❑ ❑ ❑ ❑ q <br /> 00 00D0o000g0o00000 <br /> o ❑ ❑ d❑ ❑ ❑ DODO ❑ ❑ ❑ D ❑ oo <br /> D ❑ 00 ❑ ❑ ❑ 00000000000 <br /> op <br /> co <br /> � ❑ ❑ a ❑ ❑ ❑ ❑ a ❑ a ❑ ®❑ o ❑ a( ❑ ❑ <br /> 0 Instructions:Send to Energy Labs via UPS C/S Ink: Sols Present Yes allo Q <br /> o <br /> v (J-3,�' Del vveer Via: C/S Charge l] , Temp. °C/tce Semple Pres.Yes o No r <br /> Relinquished4,,,4j�,er' [. Jrf►rL SRG�G Date/Time:@'�.l Relinquished By: 1Date/Date/Time: Received By: Date/Time: <br /> /W V r./ .� J <br />