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® HAZEN RESEARCH, INC. <br />1-IAZEN 4601 INDIANA STREET <br />- GOLDEN, CO 80403 <br />Phone - (303) 279 4501 <br />Fax - (303) 278 1528 <br />CHAIN OF CUSTODY RECORD <br />Customer Information Billing Information (If different) <br />Clien! Name: DGMC Billing Name: <br />contact: James Bender ~ Billing contact: <br />Address: 5529 US Highway 64 Billing Address: <br />Farmington, NM 87401 <br /> <br />p - -p!o <br />Phone: 505 632 1276 Fax: PO #: <br />Pr <br />oject #: <br />n <br />~~ ~ ~ <br />~ <br />Sampler's Name(s) (Print) ~~,~~ ~GN~~~ (Signature) ~~ ~'~`"`~t <br /> <br /> <br /> <br /> <br /> <br />ample Identification <br />Sample <br /> <br />Date <br />and <br />Time <br /> <br /> <br />~ <br /> <br />~ <br />~ <br /> <br />o <br />~ <br />~j <br />~ <br /> <br />ti <br />~ <br />~ h <br />~ <br /> <br />~ <br />'o <br />z° <br />;, <br />°. <br />F <br /> <br />° i/ <br /> <br />- <br />z <br /> <br />a <br /> <br /> <br /> <br /> <br />nalyses Required <br />Aod r`t I <br />v .~ nd rr/ 8 m <br />b <br />1 <br />P <br />C <br />Conductivity, pH, Sulfate <br />%CJCr /'G ~ (j d2r" rOrJ G /~ ~° p 1 P B Cyanide <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />ry) DW=Drinking Water WW=Wastewater SW=Surface Water SO=Soil GW=Ground Water SL=Sludge HZ=Hazardous O=Other <br />~~ <br />(2) P=Plastic G=Glass O=Other <br />(3)N=Nitric Acid U=Unpreserved C=Cooled S=Sulfuric ACitl B=Sodium Hydroxide T=Sodium Thiosulfate Z=Zinc Acetate O=Other <br />Relinquished by n / ~ ~ Received by Date/ Time <br />Relinquished Received by Date/ Time <br />Relinquished by Received by Date/ Time <br />/ <br />Shipped by ~~~ ~"/""r <br />o ~ ////~ •7 Date/ Time <br />Gz~ ceived for L y ` <br />~ Date/ Time <br />~-3 ~/ovo <br />Methotl of ipment Requested Turn round Time <br />Standard Rush (Must be approved, additional charges apply) <br />Lab use only <br />COC Nitrate Nitrite.zls <br />