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ACZ Laboratories, Inc. ��� • <br /> 2773 Downhill Drive Steamboat Springs, CO 80487 (800)334-54 ff <br /> Name: Z yZ Address: fox , <br /> Company: {'✓ Q _Ib alwzi ;vv e eli-0 11 <br /> E-mail: Telephone: 3`�j 2-4 2-—G/'76 <br /> Copy of Report to: —I <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: S mpler's Site Information State Zip code 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#: s✓ w <br /> m <br /> PO#: <br /> .-r <br /> Reporting state for compliance testing: c v, <br /> � C? <br /> Check box if samples include NRC licensed material? c <br /> IDENTIFICATIONSAMPLE 41: <br /> v Matrix SW(Surface Water) GW(Ground Water) WW(Waste Water) DW(Drinking Water) SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> .,.� <br /> Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> RELINQUISHED <br /> L fJ� <br /> LTMODP0028f322 White-Return with sample. Yellow-Retain for your records. Page 22 of 22 <br />