Laserfiche WebLink
<br />CHAIN-OF-CUSTODY FORM <br />rte. <br />ENT "7'i~_s'L~..:<.,,,<<:: -,tee; .•'y~~:yy,rpr_c <_ <br />ADDRESS E=-~ ~,: ~ ~, ~; <br />PHONE ~`: ~ ~ -.~ ~i :;; FAX L. `~ ~ :3 `~ 91 <br />PROJECT 1 ~;-, t-~'r~ .~i ! ~ ~ 1 <br />SAMPLER'S SIGNATURE <br />- ~ • ~ ,- <br />. -,~-- . , .~~~ _~ _ ~~.ic,_ c ~.,~,~, <br />Enviro-Chem Analytical, Inc. <br />68S West Gunnison Avenue <br />Suite 108 <br />Grand Junction, CO 81SOS-7249 <br />(970)242-6154 phone <br />(970) 245-9270 fax <br />7 / <br />`~% <br />~, ; <br /> Sample Sample Anaiysisq i~ N,'o. of ~, <br />h f.. .._ ,~ ~ ~ { <br />,'' <br />? <br />` <br />- <br />Sample LD. Date/Time Location .~:; ~ ~•~ _ <br />~ <br />~ u <br />Containers <br />a :~ r= ~ ~ <br /> <br /> ~ r. ~- t-•i -~°~ G <br /> <br /> <br /> <br /> <br />~ x, ~ K_ Wit, <br />~ <br />~, i:.~-Li-a:. ra <br /> <br />~/t 1• .. F C. t.. :x <br /> .. - c~ti ~'iJ <br />t~ ~~ ' y', 7p._ i r <br />i (C> ~7. I•'.. a c:. f <br /> JS: `{ilc8 ~ ~ <br />~ <br /> / <br />Relinquished By: ,----; -~ = ~:~'-•..- :_.---•- <br />Date(fime :'r- ,%... n h,'- ~ : ~~_r; ;,.,., <br />Relinquished By: <br />Date/Time <br />FOR LAB USE ONLY <br />Seals Intact: YES NO <br />Received in Good Condition <br />Special LnstrucHons: - <br />Accepted By:.'. ~ ~ ~` <br />DatefTime ' .~ ~ : ` ~ ~ ~ . - <br />Accepted By: <br />Date/Time <br />Preserved Property:: YES NO <br />How <br />YESf NO Adequate Sample Received: -YES NO <br />Holding Time Met: YES NO <br />Delivered By: HAND USPS FedEx <br />UPS Other <br />