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CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES REQUEST <br /> �1 Evergreen Analytical Inc. Page of <br /> COMPANYL60 SOL 4036 Youngfield COMPANY CONTACT(print) 2P—• <br /> A SZ Wheat Rrdge. Colorado 80033 <br /> 4s <br /> ADDRESS 4 � E, � Vim. / \A (303) 425-6021 PROJECT I.D. <br /> / \ FAX (303) 425-6854 <br /> CIT ao STATE ZIP JL'Z P.O N <br /> PHONE N le —� FAX M FAX RESULTS Y I N TURNAROUND REQUIRED' <br /> Sampler N -expedite urnaround subject to additional fee <br /> (signature) <br /> MATRIX ANALYSIS REQUESTED <br /> (print) �V <br /> x y N <br /> F O 0 0 ` O • <br /> Evergreen Analytical Cooler No. 'm o h \u'tl' ��r•• <br /> a 0 �_ w v m ro n ci C7 O <br /> O <br /> U m m n m m V <br /> ° C n wo f v wo m o <br /> z ti �ry <br /> `C <br /> No <br /> DATE 0 <br /> IDENTIFICATION SAMPLED TIME tes <br /> /j,,✓APwv//to /o i r Z <br /> n,c.•c_ ,P t4 <br /> ICn 2 1 <br /> ;r I <br /> Instructions: 0,12.) G �,rr�a3 S /✓Bat/y p���o/1 Li �� Si. <br /> Wt� sMr — tJ �02 — dents IF r�,refit,� <br /> hed ure) Date/Time Rec v d .(Signature) Daterrime Relinquished by:(Signature) DaterTime Received by:(Signature) Daterrime <br /> ure) Datei ime Rec edby:(Signa el ime Relinquished by:(Signature) Datei ime Received by:(Signature) Dalei ime <br />