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41I <br /> Chain of Custody Form -^�` Colrado <br /> Re,fort To,Information' t :° \ t"tt ' c •i 'lc " Bill To Information If different from re rt to`) ;Proinet Name a' t l':114.-1.11 Ano�ytic <br /> al <br /> ..ar..+ <br /> , _ . &.1 ..Y Z �aLt .4¢x a ,R..i .re .i ari� :t.....nr.•. ,...�+a4 klY .re•.�./ �J�°1i xLABOAATORIES.INC. <br /> Company Name: A4f 5 ,drµ.(s Company Name: /ti 11 N-J'vv,. <br /> �•�- j Briehton Lab <br /> Contact Name: !7°4k M'I t Contact Name: 235'- of240 South Main Street <br /> Brighton,CO 80601 <br /> Address: Address: Task Numbe' Lakewood Lab <br /> 3O SD 6'ti-h I1 verve-1 5 �.0 CAL Task No. I - 12860 W.Cedar Dr,Suite 100A <br /> 1130912021 Lakewood CO 80228 <br /> ff'' Phone:303-659-2313 <br /> CityC9y Stated Zip 1043q City State Zip JML Fax:303-659-2315 <br /> Phone: 770'5 35-i 313 Fax: Phone: Fax: www.coloradolab.com <br /> Email: 1M:l1c►'@°�(ro$.Co,�- Email: <br /> Sample Disp.Date(LabUse Only) <br /> ✓ <br /> Sampler Name: Ill ei..eq- Mit <br /> 114✓ PO No..:23}f -01 <br /> ;,q'10,A - '; 1;vr i"I; .tt.Sample Matrix(Seleet One Only)tkt ? =I 'con, >%%1111 t , , ', ;;.;, <br /> Waste Water ❑ Soil 0 Plant Tissue 01}1, p - '.,. o <br /> Ground Water Sludge 0 Other 0 ' 'v - o <br /> Surface Water ❑ Compost 0 ':(.5 441, ii " ' "' <br /> w, st'Z m <br /> •Date . Time ' 'S . ,4` --' i , ,-,`;,Sample1D + : '" ; _ t}�,. ,.t, ':, •Z kO o0' QS a <br /> x 1418 1'.2 ,. .at;:ti�--3. 1o! ix ...\. X = <br /> gilt/is „2 :21r, n - 1 .' �1 - _' x _ <br /> 1 y 1 • <br /> K L <br /> vi .5 <br /> , <br /> u , . 1.' <br /> •• , t a• <br /> . <br /> M 't}+ <br /> :it ` <br /> .F <br /> Instructions: as Info: Seals Present Yes in No❑ <br /> Deliver Via: ti/J C/S Charge 0 Temp. 1) °CAce 1 Sarapk Pres.Yes$No 0 _ <br /> Reli ished: Date/Time: Received By: Date/Time: Relinquished By: Date/Time: Received By: Date/Time: <br /> 1(1Z[i1 10.x5 j,-. R1r11($ <br />