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CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES REQUEST <br /> Evergreen Analytical Inc. Page_.ot <br /> COMPANY E. L60 _TP 4036 Younghelo (p ) <br /> r .- /^� wheat Ridge.Colorado 80033 COMPANY CONTACT riot r--- A <br /> ADDRESS 4s G' E. S Z� AVM. / \ (303) 425-6021 PROJECTI.D. <br /> /,� FAX (303) 425-6854 <br /> Cl STATE 40 ZIP J�u P.O N <br /> PHONE N t'o—/ FAX N FAX RESULTS Y I N TURNAROUND REQUIRED' <br /> Sampler N 'expedite urnaround subject to additional fee <br /> (signature) MATRIX ANALYSIS REQUESTED <br /> Mty� <br /> (print) ,V <br /> u m 3 <br /> Evergreen Analytical Cooler No. iF <br /> m h m o H a y <br /> in <br /> to ✓° E m H <br /> O - .2 c o o y v o m ut h D <br /> °� oit <br /> p� <br /> SAMPLE DATE o A o — r ;. o z a m a cm ¢ w o S <br /> IDENTIFICATION SAMPLED TIME z 3 o f m a s r a m ti ti o o (L l Notes <br /> lolleyllr zZ �QYt <br /> I I <br /> l <br /> ct <br /> Instructions: '[., P 67G� A ac�s S /,&4U-f r7f_-X4/1 Li act SA-0614) <br /> rtk M rw� 52;2 K' — � nt..R /F i� <br /> "qu <br /> ad by:(Signature) Dater rime Rec v .(Signature) DateMme Relinquished by:(Signature) Dat i ime Received by:(Signature) DataMme <br /> /L z 14:P� <br /> elinquis e0 by:(Si nature) Dat i ime Rec ed by:(Signs i ime Relinquished by:(Signature) Date/Time Received by:(Signature) DatarTlme <br />