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.. <br />JOIIN C. KIIPIIART & CO. , <br />G~~ND JUNCTION 1~~0~~T0~I~S ~ .: ~. <br />43!! NORTH AV[NV[ • PNON[ (Y70) 212.7018 • FAX 243.723E ~~ ORANO JUNCTION, GOlORA0081601 <br />CHAIN OF CUSTODY FORM •' <br />Company Name -S ~~ ~~~~ /1z~.1~~ _~ ,~~d <br />Contact ..~~'-- ~~---~-`----__-"-_-..:~_~..__~.~.. <br />Address----~~ &~^.C_'L-~~x--------------------- <br />Phone number___~~~_~ ~ _ S'p a -~~~--- ----- <br />~- ___-- FAXf! _ .~ <br />Pon - ~_ <br />--------------°--- Project name---------°-°-------- ------- <br />Special Requests: <br />( .) RUSH for extra charges, <br />( ) FAX when done - give number <br />( ) CALL when done - give number <br />( > OTHER <br />above <br />above ' <br />USE THI8 AREA FOR ONE SAMPLE ONLY: <br />Sample name= ~ ~~~~_--_---__ / ______ <br />DATE: _~.~~ _~__ ____TIMEe_ 'f>!Si°~ __SAMPLERt <br />CONTAINER(S): NUMBER TYPE <br />ANA-L7-VSI9 REQUIRED: <br />--..L _v ~ fa ~-_ f~r~ ~J' -------- <br /> <br />USE THIS~AREA FOR ONE SAMPLE ONLY: <br />Sample name:__ ~4[~ ~,QS 7~__ _ _ _ _ _ <br />DATE: ~~,_D~_ __TIME: g'1_s~~ SAMPLERe ~ _~s~~____ <br />--- - --- <br />CONTAIN <S): NUMHER_____ TYPE______ _____ PRESERVATIVE ~/oL2~ <br />------ <br />ANALYSIS RFF,,c~~U~I }~ED: <br />-------------------- - -------------------- -------------------- <br />-------------------- --------------------- -------------------- <br />-------------------- -------------------- -------------------- <br />RELINQUISHED HY SppppI~PLER (signature) ____ _(.~(/ ~,_,~_!'_ 5/(J•1- _ <br />TO (signature): /5~'+~s•.__~ _~'~st~_____ _ DATE,. TIME _yT~703 _~pn <br />-------- <br />RELINQUISHED BY:--~_--'^_--~--_----__"_~---_----~_"-~__~~----------- <br />RECEIVED HY~ __________ DATE, TIME_____________ <br />--------=------------ <br />RELINQUISHED HY: ------------°-----~---"---_--__~------------ <br />-----v~. <br />RECEIVED HYe_______________________________ DATEt TIME____________ <br />RELINQUISHED HYt--^------------ --°-------------°-------'-~-- <br />------ - <br />RECEIVED HY:_______________________________ DATE1 TIME_____________ <br />NOT.E5:.Signature affirms representation of the organization or person <br />requesting the'analysis• and agreement to the TERMS AND CONDITIONS. <br />on Special handling.may require additional charged. <br />21R <br /> <br />