Laserfiche WebLink
CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): / 7 jL i 2 <br />/ COC # ~ $ $ 6 2 - <br /> <br /> <br />L Invoice) to: (circle one or both) ~ (_ <br />Name to Appear on Report and Invoice: cc: (Report) - ( <br />yQMP.Stn ~ Mirwnp L6 /wAa.KV Z- ~ibut• .J ~~w-1J~7 <br />aboratories, Inc. <br />2773 D <br />hill ~ ~, ~ S~~~r~ ~ ( ,~ ~ ,~. <br />/, Sty C''''' <br />own <br />Drive <br />Steamboat S <br />rin <br />CO 80487 - 2 ~ GO 8d Z.O• <br />p <br />gs, <br />(970) 879-6590 • (800) 334.5493 Attn: ~n,rr ~~Y Tel:~y~7)~~r~0 Attn: sT e1' •jo3 2 OOS <br />Project or P.O. # 22 'L A NALY SES REQU ESTE D <br />l~ulCrlo9 M'"-e' ~a•L' ~r~r-"JL`{• <br />1 ? I for~,f SRc v ceE,~ Ro~ SCLSY4 <br /> <br />Gc•eed~rt- CJ g I l3o ~ <br />w <br />z <br />Z <br /> <br /> <br />yl REMARKS <br />Shipped Via: FED X_ UPS_Hand_Other c°, .~•; <br />~' • <br /> <br />SAMPLE IDENTIFICATION <br />DATE <br />TIME <br />Sample <br />Matrix <br />a ~ <br />/XJ <br />EL+ <br />~~~ ~o-~vLr>~~5 <br />1 <br />t2- 8 Trtv.ch Tv.12,\ l2-y. oS:lS 5 W 5 x D . S2 ~ y.' c ~~ Zz <br />~1.- (_• I Z4 ti; yS 5 W ~ X 9 (, 3 ~ /. / °C ~ac1: Z 5 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />• Matrix Options: SW (Surlace water) • GW (Grountl water) • WW (Wastewater) • DW (Dr,nking water) • SL (Sludge) • SOIL • OIL • Other (SpecAy) COMMENTS <br />SAMPLE DISPOSAL OPTIONS -Please complete section A, or choose one option tYom sections BAND C. <br />Proper charges will be assessed. <br />(A) Long-term storage <br />Hold until (date) <br />for future analysis. I/Sample /s Non-Hazardous <br />ocal Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client (C) I/Sample is Hazardous <br />t) RCRA-Permitted Facility <br />2) Return to Client <br />RELINQUISHED BY: (SIGNATURE) DATE TIME EIVE <br />B <br />Y: (SIGNATURE) DATE TIME PAGE # <br /> ,{ <br />A <br /> OF <br /> <br />~.. <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Goltl -Keep for your records <br />