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Chain of Custody Form , 02 �-). 6 , <br /> Report To Information Bill To Information(If different from report to) Project Name • • s Colorado Anal tial <br /> •Laboratories. ani_ <br /> Company Name:Colorado Analytical Company Name: Same As Report To 180911125 <br /> Bri>hton 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. CAL Task No. 12860 W.Cedar Dr,Suite 100A <br /> 180911125 Lakewood CO 80228 <br /> Phone:303-659-2313 <br /> City Brighton State CO Zip80601 City State_ Zip Fax:303-659-2315 <br /> ARF <br /> Phone:3036592313 Fax:3036592315 Phone: Fax: www.coloradolab.com <br /> Email:stuartnielson@coloradolab.com Email: Disposal Date(Lab Use Only) <br /> Sample Collector:Valen Lickley PO No.: <br /> Sample Matrix(Select One Only) <br /> Waste Water ❑ Soil ❑ Plant Tissue ❑ o <br /> aW <br /> Ground Water® Sludge 1:1 other c° <br /> Surface Water ❑ Compost ❑ wo <br /> o .avE <br /> Date Time Sample ID z o o C) c7 <br /> 9/11/18 1427 180911125-01D MW-1 I ® ❑ 121 ❑ ❑ ❑ El El El El El El ❑ ❑ El El ❑ ❑ <br /> • ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ a ❑ <br /> n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ El ❑ ❑ I II I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o ❑ ❑ o ❑ <br /> ❑ n ❑ ❑ ❑ ❑ ❑ ❑ 00 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E E 0 ❑ 00 ❑ ❑ ❑ El ❑ ❑ 00ElU00 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Instructions:Send via UPS to Hazen Research C/S Info: Seals Present Yes 0 No 0 <br /> tp 7V1 <br /> ( Klct FtStia4 / Deliver Via: C/S Charge❑ Temp. °C/Ice Sample Pres.Yes❑ No 0 <br /> Relinquished By: Dat /T' e: . _, eceiv� -By '/ Date/Tiln Relinquished By: Date/Time: Received By: Date/Time:/1,-ii,five ,...., <br /> 4 <br /> ,,, 7g , 4 <br /> page 5 of 5 <br />