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OZ Laboratories, Inc 32 • ' <br /> 2773 Downhill Drive Steamboat Spnngs,CO 80487 (800) <br /> Name: Address: <br /> Company <br /> E-mail: C r � e�ephone: <br /> Name h' Nlephlrve: <br /> mail: Ca,� t'�y •� <br /> company: <br /> Name: Address: <br /> Compan m '' <br /> E-mail; < r •C T 9Iephone: <br /> If sam s)received past holding time—(HI),or if insufficient HT remains to complete YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO <br /> ta-was ncZ.e curd drn w ft m mr,<=If,ww..-Ver, 'wo-w uz WE a,�«e.a n..na.1.e.e.ry...,...,,a Kr•.�..t"e ee..e e.w+bw <br /> Are samples for SDWA Compliance Monitoring? Yes No <br /> N yes,please include state forms.Results will be reported to PQL for Colorado. <br /> Samplar's Name: r Sampler's Site Information Stab C n Zip eode�Time Zone <br /> ry.w.K r&Q"w kft ad Ndkv d as Ada.f ur.& W a.e ws.eeenur�Y ma unyaw/ruvmo r <br /> •Sampler's Signature: �p oft Own*,Mawwy.h­Id ed�„y ti5,u - <br /> Quote#: w <br /> PO#: <br /> Reporting state for compliance testingi <br /> Check box if samples include NRC licensed material? ❑ r, �� <br /> 0 <br /> IDENTIFICATION D,4TE7PAE Matrix ate <br /> .— alai ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ LOU ❑ ❑ <br /> ❑ ❑ 111011 ❑ ❑ ❑ <br /> Matrix SW(Surface water)•OW(OrWrd water) WW(Waste Water)•OW(odnkxv Water)-SL(Sktlge)•SO(Shcl-OL(04)•Other(Specify) <br /> 0 f L <br /> --0 Please refer to ACZ s terms&condidons located on the reverse side of this COC. <br /> M RELINQUISHED BY DATE TIME RECEIVED BYi DATEJIME <br /> ...moo <br /> -_� FRMAD050.06A4.14 White-Return with sample. Yell w-Retain for your records- <br /> Page 36 of 36 <br /> L66632-2107141355 <br />