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Chain of Custody Formdiriii ` <br /> Report To Information Bill To information(If different from report to) Project Name • 1 Lolorado Analytical <br /> t nhurdlurles, int.. <br /> Company Name:Colorado Analytical Company Name:Same As Report To 18091 1125 <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. 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.culoradolab.com <br /> Email:stuartnielson@coloradolab.com Email: Disposal Date(Lab Use Only) <br /> Sample Collector:Valene Lickley PO No.: <br /> Sample Matrix(Select One Only) <br /> kWaste Water ❑ Soil CIPlant Tissue ❑ O <br /> I.) <br /> Ground Water® Sludge El Other ° <br /> Surface Water ❑ Compost ❑ El (.3 <br /> o 0 <br /> — ° .10 -(.5 g 8 <br /> P. <br /> Date Time Sample ID z c, o U v <br /> 9/11/18 1427 180911125-0/F :t/II-/ I ® ❑ El ❑ ❑ El ❑ El ❑ El ❑ ❑ ❑ ❑ [I] ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> O D 111111001110000 [1100000111 <br /> ❑ ❑ 0001100111011111111100C1111111 <br /> ❑ ❑ Ell ❑ ❑ f—I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ III ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ I-1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I—f ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> n ❑ ❑ 0 ❑ 0D0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E D ❑ ❑_ ❑ DELI ❑ ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ <br /> N instructions:Send via Fed Ex Same Day so Eurofins C/S Info: Seals Present 1'es❑No 0 <br /> m <br /> 01 L <br /> 011 0 Deliver Via: C/S Charge❑ Temp. /Ice Sample Pres.Yes 0 No 0 <br /> Relinquished By: Date/Time: ceived By: Date/Ti linquished B Date/Tim Rete ;7ate/Time: <br /> 4J(iciii,iii/A" P //,9- /1 2rhwt4A0.11.11‘ A.4 evil, '115 <br /> N BSG 6/131)t, 4)9 <br />