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r � • • � <br /> ACZ Laboratories, Inc. L 71 <br /> 2773 Downhill Drive Steamboat Springs, CO 80487 (800)334-5493 <br /> Name: , r. e- Address: I'IMCompany: Ct $f L{27 <br /> E-mail:zit%Aroa s, ;,,,, Tale hone: a M4 qSWl> llO d <br /> Copy of Report to: <br /> Name: S E-mail: <br /> Company: $, r`•�J Telephone: X.X- S S.SC;t <br /> •Name: 5.2..i Address: )`Lbw Company:d tr4r n f•t) tZ> <br /> E-mail: Telephone: <br /> if sampie(s)received past holding 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"then ACZ MN contact GMnt for furgw instruction.N MWW"YL-r nw'W is Indicated,ACZ wM proceed eNTh the requested analyses,avan N HT IN ,and dab wM be*WW*d <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 /> Sampler's Name: Sampler's Site Information State ,*e> Zip code_Time Zone Al <br /> •I dut to tin audmftlty and vela ty of this sample.I understand Nut Intensionally rnlelahMng dw tin eldese oeatlen orSamplers Signature: b.o msi wwn it*sample In mWemy,As considered fraud and punishable by state Law. <br /> PROJECT •• • <br /> Quote#: <br /> m <br /> PO#: <br /> Reporting state for compliance testin : ^� <br /> Check box if samples include NRC licensed material? o •c�,T <br /> r • • • vt �.J <br /> 3 ..-. 41,> 6- 1 V <br /> -ate s <br /> 0 <br /> N Matrix SW(Surface Water) GW(Ground Water)-WW(Waste Water)•DW(Drinking Water) St.(Sludge) SO(Soil)•OL(Oil)•Other(Speify) <br /> 3 <br /> =low NZILTAIIAM <br /> -�O <br /> C <br /> ne� <br /> Please refer to ACZ's terms&conditions located on the reverse side of this COC. <br /> -- t <br /> RELINQUISHED <br /> D• D. <br /> 2.i J7- <br /> L71/tS3-LZCJ:i"L3��1J� White-Return with sample. Yellow-Retain for your records. Page 19 Of 19 <br />