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FR7'i'i Rav R <br />'Acculabs Inc. Lab Number <br />[ ] 1725 W. 17th. St. Tempe AZ 85281 480-967-1310 Fax 967-1019 ~- ~~ ~ ~ (~ 04$- ~ <br />[ ] 4455 S. Park Ave. Tucson AZ 85714 520-807-3801 Fax 807-3803 Repon <br />[ ] 2029 N. 41h St. Flagstaff AZ 86004 520-774-76a3 Fax 774-7648 Due Date: <br />[ ] 1046 Olive Drive Daws CA 95616 530-757-0920 Fax 753-6091 <br />[ ] 75 Sultle St. Durango CO 81301 970-247-4220 Fax 247-a 227 <br />I 14663 Table Mountain Dr. Golden CO BOa03 303-277-9514 Fax 277-9512 <br />[ J 992 Spice Islands Dr. Sparks NV 85a31 775-355-0202 Fax 355-0817 <br />1 <br />Client I ~ ~ L ~ <br />Fax Results Y N <br />Page of <br />Address ~{y2 <br />K ~-/Z Z O PUBLIC WATER SUPPLY INFORMATION <br />/ <br />City, State & Zip ~ ~ V ~ gy3 Z System Name <br />Contact T PWS No. Report to Stale/EPA Y N <br />Phone Couector's Name POE No. DWR No <br />Fax Protect Name Collection Point <br />P O. Number Protect Number Location (City) f• <br />' SAMPLE TYPE CODES _ Analyses <br />DW =drinking water TB =travel blank <br />WW =waste water SD = solitl <br />MW =monitoring well SO =soil <br />HW =hazardous waste SL =sludge Compliance <br />Monitoring <br />© <br />N S <br />a <br />m <br />P C <br />° <br />~ <br />a Requested <br />V f. ~ <br />U 0'f <br />-.a_ ~ <br />TURNAROUND TIME REQUESTED e I ~ f, <br />Standard Lab Manager n ~ !r <br />RUSH Approval T <br /> <br />y e <br /> <br />r ~ <br />i <br /> <br />Special <br />P <br />s V <br />LU <br />V <br />CLIENT'S SAMPLE ID/LOCATION Date .Time a ~ <br />Spl. No. <br />l.Jell Y1 1-5.90 9~ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Instructions/Comments/Special Requirements: <br /> <br />SAMPLE RECEIPT Date Time Samples Relinquish d By Samples Received By <br />Received Cold Y N - •~ 9 ~ ^~ <br />Custody Seals Y N <br />Seals Intact Y N <br />No. of Containers <br />Acculabs' terms are: Net 40 (Payment must be received by the date shown on the Invoice or any discount is void) <br />To the maximum extent permitted by law, the Client agrees to limit the liability of Acculabs Inc. for the Client's damages to the total compensation received <br />unless other arrangements are made in writing This limitation shall apply regardless of the cause o(action or legal theory pled or asserted. <br />A301E <br />