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ACZ Laboratories, Inc. C����a • <br /> 2773 Downhill Drive Steamboat Springs, CO 80487 (800)334-5493 <br /> Name: i z— l Address: 6 -4 ,.✓ e�,j"' T76 <br /> Company: <br /> E-mail: A,6"? � c� 62r Telephone: ,70 —2 2�—CJj76 <br /> . . . <br /> Name: E-mail: <br /> Company: Telephone: <br /> Invoice to: <br /> Name: Address: <br /> Company: <br /> E-mail: Telephone: <br /> If sample(s)received past holding time(HT),or if insufficient HT remains to complete YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO <br /> If"NO"then ACZ will contact client for further instruction.If neither"YES"nor"NO"is indicated,ACZ will proceed with the requested analyses,even if HT is expired,and data will be qualified <br /> Are samples for SDWA Compliance Monitoring? Yes No <br /> If yes,please include state forms.Results will be reported to PQL for Colorado. <br /> Sampler's Name: ! Sa er's Site Information State /'[J Zip code Sd Time Zone <br /> `I attest to the authenticity and validity of this sample. I understand that intentionally mislabeling the time/date/location or <br /> .Sampler's Signature: tampering with the sample in anyway,is considered fraud and punishable by State Law. <br /> PROJECT • • <br /> Quote#: <br /> m <br /> PO#: <br /> Reporting state for compliance testing: p <br /> Check box if samples include NRC licensed material? c /yor- <br /> • a <br /> r <br /> Matrix SW(Surface Water) GW(Ground Water) WW(Waste Water) DW(Drinking Water) SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> AEMARKS <br /> Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> RELINQUISHEDD• D• <br /> L2bW6DWM8 t3913 White-Return with sample. Yellow-Retain for your records. Page 26 of 26 <br />