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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): / ~/~/ ~ <br />( <br />o Coca 15 3 6 4 <br /> <br /> <br />A ~ Name to Appear on po and Invoice: cc. <br />~ (cirGe one or both) ^- <br />vg~a) to <br />Report) (In <br />( ~~ I <br />Laboratories, Inc. <br />30400 Downhill Drive <br />Steamboat Springs, CO 80487 <br />(970) 879.6590 • (800) 334-5493 o <br />G+ ~ <br /> <br />Attn: Tel• ttn: <br />G^ g0 O 2 <br /> <br />Tel: <br />_~. <br /> <br />Project or P.O. # ~'1 (O g A NALY SES REQU ESTE D <br />~~I' n~ oL IOt 81/ <br />d = REMARKS <br />Shipped Va: FED X_ UPS Hand _Other ~ • <br />SAMPLE IDENTIFICATION DATE TIME Semple <br />Mat <br />n>< <br />• <br /> r -- <br />11 <br />~~l <br /> <br /> <br /> J <br /> <br /> <br /> <br /> <br /> <br /> <br />' Matrix Options: SW (Surhace water) • GW (Grountl water) • W W (Wastewater) • DW (Drinking water) • SL (Slutlge) • SOIL • OIL • Other (Speedy) COMMENTS <br />SAMPLE DISPOSAL OP770NS -Please complete section A, or choose one option from seetlons B AND C. <br />Proper charges will ba assessed. <br />(A) Long-term storegs <br />Hold until (date) <br />for Mure analysis. (B) 1! Semple Is Non-Hazardous <br />t) Local Disposal <br />2) RCR.4 -Permitted Facility <br />3) Return to Client (C)1t Sample Is Hazardous <br />7} RCRA-Permitted Facility <br />2) Return to CIieM <br />RELINQUI HED BY: (SIGNATURE) DATE TIME RECEI D BY: (SIGNATURE) DATE TIME PAGE N <br /> ~ - ~ - 8 ~ !~ y odv <br /> OF <br /> <br />White -Return w/ sample Yellow ~ Return w/ sample Pink -Return w/ sample Goltl -Keep for your records <br />