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ACZ Laboratories, Inc.� 1(pCHAIN of CUSTODY <br /> 2773 Downhill Drive Steamboat Springs,CO 80487 (800)334-5493 <br /> Report <br /> Name: �N Address: <br /> Compan y eum <br /> E-mail a Telephone: <br /> Copy of Report to: <br /> Name C /• E-mail: of Co <br /> Com any Telephone: <br /> Invoice to: <br /> Name: / .1 Address: <br /> Company <br /> E-mail:CIA,, <br /> X-W C7. Telephone: <br /> If same e(s)received past h Iding time(HT),or if insufficient HT remains to complete YES <br /> f� <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO _f <br /> "NO"then ACZ will contact client for furtlwr instruction.If rraither-YES-nor"NO"is indicated,ACZ will proewd Ath the requested analyses,*von If HT is oxpirotand daft 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 /> Samplers Name. Sampler's Site Information State (:,c") Zip code ___Time Zonet <br /> •i cleat to the•u bo ty and validity of this sample. I understand that inbnhonally mislabeling the time/d.Wooshon or <br /> "Sarpl@rS Signature: "—�/ tampering wile dra sample in anyway,m varlaw.raa fraud and punishable by ewr.I-- <br /> PROJECT INFORMATION • <br /> Quote - <br /> m <br /> PO#: E <br /> R <br /> Reporting state for compliance testing: o cLU <br /> Check box if samples include NRC licensed material? o <br /> • • • • aa `a <br /> �W is < S Wr <br /> �f. W -, <br /> Matrix SW(Surface Water) GW(Ground Water) WW(Waste Water) DW(Drinking Water) SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> REMARKS <br /> r 4 <br /> O <br /> N <br /> 3 <br /> —=-"o Please refer to ACTS terms&conditions located on the reverse side of this COC. <br /> r s S 3 -5 <br /> —S <br /> oct <br /> FRMAD050.06.14.14 White-Return with sample. Yellow-Retain for your records. Page 15 of 15 <br /> L64296-2102241528 <br />