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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use ~nly): / 2 / ~ / / <br />L COC a 16 6 5 <br /> <br />ACZ Laboratories, Inc. <br /> <br />2773 Downhill Drive <br />Steamboat Springs, CO 80487 <br />(970) 879-6590 • (B00) 334-5493 ort) - (Invoice) to: (circle one or both) <br />Name to Appear on Report and Invoice: cc: (Rep <br />N rrl P i + n ~ ~ (~ .v LvA f Anr f £ ~ ~c <br />fv `~ ra l ~ der n r ni Si' /P } 74 U t l~ S <br />~ ~ A 94 / o E 17f N t/F (' ~ 0 <br />n Y is n ~ r + r n , <br />Attn: ~ lah fUx Tel: yl~r- qP,t ~S0 Attn: Sr LL el~y <br />5 I <br />Project or P.O. A A NALY SES REQU ESTE D <br />BULL ~ U L M MI E <br /> <br />runFST srR~) ~>: ,? ~ szsri <br />~~1 <br />cRtrn£, ~v ~r130 rn <br /> <br />w <br />~ <br /> <br />~ <br />~ w <br /> <br />REMARKS <br />Shipped Via: FED X_ UPS_Hand_Other $ ~ a <br />SAMPLE IDENTIFICATION DATE TIME sample <br />Matri>< ~ ~ FI£t t~ PRRAmQTFk 5 <br />I-99 Hw•3 t/7/5 14:1 Gtn/ S X N; .~a• 6.9° 5 <br />- / l~l~ pl C LL Fr w F~ O <br />1-99 1RFntrFt tA)LFT 1~7 jb(OS StJ S °c' <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />• MaVlx Option: SW (Surlace water) • GW (Grountl water) • WW (Wastewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Speciy) COMMENTS <br />'SAMPLE DISPOSAL OPTIONS - Pleese complete section A, or choose one option from sect/ons B AND C. <br />Proper charges will be assessed. Sa fi pl ~ 5 (~rPl t ^ too I r r 5 w/ 5..r,w <br /> <br />Gr Ire bti'~'r ~r0..~ ro)Irr},°.~ 10 <br />(A) Long-term storage <br />Hold until .' (date) <br />for future analysis. B)1I Sample Is Non-Hazardous <br />1 Local Disposal <br />RCRA -Permitted Facility <br />3) Return to Client (CJ N Sample /s Hazardous <br />1) RCRA-Permitted Facility <br />2) Return to Cliem t~£/99. T h rp £r, rtyr,,, for (ro•++ '~E/59 <br />v., I , I S H • P P P~ . <br />RELINQUISHED BY: (SIGNATUR E) DATE TIME RECEIV S I ATURE) DATE TIME PAGE N <br /> 17: oo p>» oN - 99 ~ It ~ /r,,... <br /> OF <br /> <br />r <br />r~, <br />CM <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Gold -Keep for your recortls <br />