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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): / ZZ jU y <br />! COC q 1 8 8 6 3 <br /> <br />Laboratories, Ina <br />2773 Downhill Drive <br />Steamboat Springs, CO 80487 <br />(970) 879-6590 • (800) 334-5493 Name to Appear on Report and Invoice: cc: <br />bso C~I,~rnlc~ -~- ~ ~, <br />~y1 ~~n•~ctsca C!~ ~yb _~ <br />Attn: (~k Tel- y/S /- /Sb Attn: <br />~lo-'^ 9 (Invoice) to: <br />epo - <br />aol / ~' <br />~er~e~ <br />~,, (circle one or both) <br />~w sio <br />7_a2 <br />Tel: 3p3 <br />Project or P.O. q E3k,!(cloy /y)„tip A NALY SES REQU ESTE D <br />/~oM¢d'~W~. M.. Coroya~ <br />-11 ` ~o~s~ `2 .~6s r4 <br />Cc'2Q.c~ ~ ' ~ 1 13b N <br />i REMARKS <br />Shipped Via: FED X_ UPSHand_Other ° 'A . <br />SAMPLE IDENTIFICATION DATE TIME Sample <br />Matrix = ~j~ ~ e.rarn~~e-rS ; <br />2- 1re.~ ~-v~~2t Z-y-9tj )9'30 5~ s S. ~Q. 5/S T .E° <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />• Matrix Options: SW (Surtace water) • GW (Ground water) • WW (Wastewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Speciy) COMMENTS <br />SAMPLE DISPOSAL OPTIONS -Please complete section A, or choose one option from sections B AND C. <br />Proper charges will be assessed. <br />(A) Long-term storage <br />Hold until (date) <br />for future analysis. B N Sample is Non-Hazardous <br />ocal Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client (C) If Sample is Hazardous <br />t) RCRA-Permitted Facility <br />2) Return to Client <br />RELINQUISHED BY: (SIGNATURE) DATE TIME RECEI Y• (SIG URE) DATE TIME PAGE q <br /> 2-io- i~=,3s J6 law <br /> OF <br /> <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Gold -Keep for your records <br />