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7,<,, WI <br /> Chain of Custody Form �` <br /> Report To Information Bill To Information(If different from report to) Project Name • Colorado Analytical <br /> -Laboratories, Inc. <br /> Company Name:Colorado Analytical Company Name: Same 180912021 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 Brithton 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) <br /> T <br /> Waste Water ❑ Soil ❑ Plant TissueN <br /> ❑ o j <br /> Ground Water® Sludge ❑ Other ° <br /> Surface Water ❑ Compost ❑ ❑ �.o O .o <br /> ° .oU E o <br /> Date Time Sample ID z c7 `o cI U <br /> 9/12/18 0920 /80921021-0Il 1111'-3 1 ® ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DO 111000111111111001111111110 [11111111 <br /> ❑ n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 E ❑ ❑ ❑ ❑ ❑ ❑ o ❑, ❑ ❑ o ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 1111110011111100000011101110 <br /> it <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DO E111111100011111100111011111100 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> n� <br /> i Instructions:Send to Eurofins via FedexSDto <br /> C/S Info: Seals Presen 'es 0 No 0 <br /> m () <br /> Deliver Via: C/S Charge 0 Tem /CIIce Sample Rres.Yes 0 No <br /> 01 <br /> o <br /> Relinquished By: Date/Time: eived ByDate/Time: Reli uished By: Da e/lim` e ce' e B Dai;e/Time: <br /> 6'S4- q/(moi w.cimpoiil9.12. li (3 U } i (iJ'1/A� v17.-Od q/4341'/a i i9 - <br /> //76.0 `` v <br />