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Chain of Custody Form <br /> ^.• CO��r9do- 1AnQytieQ� <br /> -FF,Mt To4Inf�ramatoo:n�al;�'.s, i: "4xx `bcth�i+'�xfaBacT�olnfor .atk.ai� fdiffe.e.rromre�+rt to �,a1 :.Pro�e.c..Namell'i; >ctVrll LABORATORIES,INC. <br /> Company Name: A4 <br /> pRO4SSidrvx.Is <br /> Company Name: Hi 11 /✓Vr <br /> B <br /> + riehton Lab <br /> Contact Name: ek M4 t*y Contact Name: Z35{ `04 240 South Main Street <br /> Brighton,CO 80601 <br /> Address: Address: Task Numbe. Lakewood Lab <br /> 30 So 6 Rvel S CAL Task No. } ' 12860 W.Cedar Dr,Suite 100A <br /> 180912021 Lakewood CO 80228 <br /> fr-- U Phone:303-659-2313 <br /> CityC1�iey State&) 0.�o <br /> Zip37 City State Zip JML Fax:303-659-2315 <br /> , <br /> Phone: 770'535-`l3"3 Fax: Phone: Fax: www.coloradolab.com <br /> Email: 11-1,11ele dif pt'a$,Cor^ Email: <br /> Sample Disp.Date(Labtlse Only) <br /> Sampler Name: ''P e‘cg. Mi Z, Po No.:2391-01 <br /> vy,— .. .•' 1 1,x o., ,,, .'t I;Sample Matrix(Select One Only) '•7, „'`' ".";FST+`? i°u,11,1 i{t b .)- `yrafti;� <br /> • 4. ,y <br /> 4 <br /> 0 Soil 0 Plant Tissue 0 � �• i �, p � .'- r <br /> Waste Water <br /> Ground Waters Sludge 0 Other 0 .I. 't•tt4 .1 <br /> 54' -` 6 <br /> . �; N <br /> Surface Water ❑ Compost 0 rte' � y' `„" 4u <br /> t <br /> o �'o a <br /> _ •Date . Tim , a „e '. ,, 1. 1r` k c .,,Sam _`ple1D `r : `. ; ► . .YFiFt,i„'t,i j Z Q 0th Cil <br /> 8 ia.:o /10- 3 io !X =tii _ <br /> 1(�Mx <br /> 4110 a ;21r, no - 1 , 1 - x` ; :. x <br /> — a • <br /> i <br /> 1 <br /> e tFt. i , <br /> 41 <br /> f+ <br /> 9 ,11 _... ., , . <br /> Instructions: CIS lafo: l Seals Present Yes 0-No❑ <br /> Deliver Via: '[6)..LC CIS Claree 0 Temp. )) °Glee i Sample Pres.Yes 0 No 0 _ <br /> Reli ished: Date/Time:` / Received By: Date/Time: Relinquished By: Date/Time: Received By: Date/Time: <br /> /110}. <br /> U Id:a <br />