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ADZ <br /> Laboratories, Inc. L&43ciS • <br /> 2773 Downhill Drive Steamboat Spnngs,CO 80487 (800)334-5493 <br /> Name: c"vi Address: <br /> E-mail: X- �c��, Tele hone: <br /> Ccpy of Report to: <br /> Marnn - _j, E-mail: 7. �.cG�-► <br /> any- 7 Te(e <br /> Name: Address: <br /> Co an I- <br /> E-mail: Telephone: <br /> If sam s received past holding me(HT),or if insufficient HT remains to complete YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO <br /> If-ra'Own W2 ww�.&. rw r ewd..me,,.If -ftS-r -ra•b.+dia 44 ACE ww p—d wM m.r.grr.na. Fy. ,i—,if err r.., a,ma m ri e.w.an.a <br /> Are samples for SDWA Compliance Monitoring? YesLai No <br /> I-8sam <br /> yes,please include state forms.Results will be reported to PQL for Colorado. <br /> amplers Name: Sampler s Site Information StateC_O Zip code ��-fifine Zone,��Signature: <br /> I>♦ers r.nanM[.xn rh.r.npe N.rry.ay,b rnnaar.d r.e„d.na or+mb.a<w wroe u.. <br /> PROJECT •' • <br /> Quote#: - - ­f �+ <br /> m <br /> PO#: c <br /> Reporting state for compliance testing: c <br /> V <br /> Check box if samples include NRC licensed material? ❑ o ` <br /> 777 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑,,,,, ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 13113 13113 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 131131 ❑ ❑ ❑ ❑ <br /> ❑ ❑ [31 ❑ 1 ❑ ❑ ❑ ❑ <br /> -C <br /> C Matrix SW(Surface Water) GW(Ground Water) WW(Waste Water)-DIN(Drinking Water) SL(Sludge)•SO(Sod)•OL(ON)•Other(Specify) <br /> .y <br /> A <br /> Wit) <br /> MINE <br /> <1 <br /> aEmor-M <br /> � <br /> ==3 <br /> Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> kRELINQUISHED BY DATE TIME RECEIVED Yc . • <br /> ­o- 3 - C - 7 Si 7 <br /> (- FRMAD050.06.14.14 White-Return with sample. Yellow-Retain for ur records. <br /> L64395-21 03091 1 1 8 Page 9 of 9 <br />