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Laboratories, Inc. L3c�s • <br /> 2773 Downhill Drive Steamboat Spnngs,CO 80487 (800)334-5493 <br /> &4 <br /> Name: <br /> Address: <br /> [company: <br /> -- 'k <br /> E-mail: 3r C/��ti' ''C l c a •c':c,t ee-• C.Cih Telephone: <br /> Name]/' ►mot / <br /> E-mail: _ y <br /> ITeleph no: <br /> Name: Address: <br /> Company. <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 /> vo-e..Acz.a cmam arw fa .r Wow ruwM.r-Wrier—W a Wft.90e,AM.a naord rw nr <br /> �Io11.ue Are dr..a w a.In.e <br /> samples for SDWA Compliance Monitoring? Yes LM No <br /> EW <br /> If Yea,Paase Include state forms.Results wifi be reported to PQL for Colorado. <br /> Sampler's Name; _ <br /> Sampler's$ib Information State C/,��.� <br /> _s.�ZIP code �' r1-lime Zone <br /> 'Samplers Signature: <br /> •re�•n.rw...m1..1.r..+Mein.Iw..r...., <br /> ..e e r.MiN1 r M1.q.�wwau.e 6.ue Ma w�h�l.Mwae ia.. <br /> jFCT <br /> RIVATION <br /> Quot@#:-) 'cf <br /> L <br /> Reporting state for compliance testing: e <br /> 0 <br /> heck box if samples Include NRC licensed material? ❑ o <br /> T7 <br /> s ak 0 <br /> S 5 7 St.✓ / ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 131 <br /> © ® ❑ ❑ ❑ ❑ ® ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 131 ❑ ❑ <br /> 0 <br /> ❑ © ❑ © ❑ ❑ ❑ ❑ <br /> Matrix SW(surface water)•GW(Ground Water)•WW(West-Water) oW(on,kr,y Water)-sL(Slu <br /> dge) so IS OL(oil) Other(Specify) <br /> ..i <br /> Please refer to ACZ s terms&conditions located on the reverse side of this COC. <br /> �( • <br /> DATE TIME <br /> kx <br /> (' RECEDVED By <br /> CA\ FRMAooso.os.ta.la :Zc <br /> I White-Retum with sample. Yellow-Retain for r records. <br /> L64395-21 03091 1 1 8 M2012032 TR12 PAR A3 pg 24 of 125 Page 9 of 9 <br />