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ADZ Laboratories, Inc.L�, )b <br /> 2773 Downhill Dnve Steamboat Springs, CO 80487 (800)334-5493 <br /> Name,. /� a Address: <br /> Compan . <br /> E-mail a Tele hone: <br /> .. . <br /> NameC �. E-mail: <br /> C o mi p an <br /> ITelephone: <br /> Invoice to: <br /> Name: (W- <br /> Address: <br /> Com an <br /> E-mail: ,-w, Telephone: <br /> If sam e(s)received past h Iding time(HT),or if insufficient HT remains to complete YES <br /> analysis before expiration,shall ACZ proceed with requested short HT analyses? NO <br /> "NO"than ACZ will contact ahem for further msum0m n.if nedher"YES"ner"NO"is indicated.ACZ will pressed with the requested analyses,oven g HT rs expin.16.nd data will M gsslitted <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. hn Sampler's Site Information State1fZ-2 Zip code ime Zone <br /> "Sampler's Signature: ' te the a"taant1 ity and avidity of this sample I understand"w intamaensiiy n+rlebeiing gw bnre/dabAosstlon or <br /> tampering wed,tin sample in anyway,is considered fraud and Punishable by St"Law. <br /> PROJECT •' • <br /> - w <br /> Quote#: <br /> PO# c <br /> Reporting state for compliance testing: o <br /> LU <br /> Check box if samples include NRC licensed material? c Q <br /> Matrix SW(Surface Water) GW(Ground Water)-WW(Waste Water)-OW(Drinking Water) SL(Sludge) SO(Soil) OL(Oil) Other(Specify) <br /> f ;'�Iy S')�4 <br /> a <br /> 0 <br /> 3 <br /> -"V <br /> �o Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> r s <br /> _— FRMAD050 06.14.14 White-Return with sample. Yellow-Reta' fo v�u r records. Page 1 O 5 <br /> 1 <br /> L64296-2102241528 M2012032 TR12 PAR A3 pg l�o{1'15 <br />