INSPEC20519

• Permit No: C1981041
• IBM Index Class Name: Inspection
• Doc Name: Inspection Report
• Inspection Date: 5/13/2003
• Media Type: D
• Archive: No

-'~ `' JOHN C. I{EPHART & CO.
~G~~ND JUNCTION L~~D~~TO~I~S
435 NORTH AV[NU[ • PNCN[ (1770) 242.7610 • FAX [phone] • GRAND JUNCTION, COLORADO 87501
CHAIN OF CUSTODY FORM
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Special Requests:
( ) RUSH for extra charges
( ) FAX when done - give number above
( ) CALL when done - give number above
( ) OTHER
USE THIS AREA FOR ONE S~MPLE ONLY:
Sample nom Q~ S,~______ _ __________
DATE:_QS~~~Q~ ____ TIME:_ 7l©__~_______SAMPI
CONTAINEF(S : NUMBER_~___TYPE _____,
ANALYSIS REQUIRED: ( /IeaF^c~ ~~,/~ /i!/r

USE THIS AREA FOR ONE SAMRLE ONLY: V
Sample name: ------------------------------------------
---------------
DATE:-------=---------TIME:-------------SAMPLER:--------------------
CONTAINER(S): NUMBER______TYPE_________________ PRESERVATIVE________
ANALYSIS REQUIRED:
RELINQUISHED bV S LER ignature)_ _ ! _ __ __` r__/__ ~ _ ,
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RELINQUISHED BYz _____________
RECEIVED BY: •____DATE, TIME
------- -------------------- -------------
RELINQUISHED BY:-------------------------------------------=-'------
RECEIVED HY:--------------------------------DATE, TIME-------------
RELLNQUISHED BY:----^----------------------------------------------
RECEIVED BY:_______________________________ DATE, TIME_____________
NOTES: Signature affirms representation of the organization or person
requesting the analysis, and agreement•to the TERMS AND CONDITIONS.
Special handling may require additional charges.
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