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Analytical <br />~Leboratories, inc <br />Client: ^ V <br />Contact: ~~ k 1 t-4~- <br />Address: (, F <br />-~ <br />Phone Number: <br />FAX Number: <br />of <br />o~ <br /> <br /> <br />4 <br />CHAIN OF CUSTODY RECORD <br />NOTES: <br />1) Ensure proper container packaging. <br />2) Ship samples promptly following collection. <br />3) Designate Sample Reject Disposition. <br />Table 1. -Matrix Type <br />1 =Surface Water, 2 =Ground Water <br />3 =Soil/Sediment, 4 = Rinsate, 5 =Oil <br />PO# 16 =Waste, 7 =Other (Specify) <br />Project Name: (}~ ~ [a ~~~ Samplers Signature: <br />Page_ of <br />FOR GAL USE ONLY <br />GAL JOB # <br />,gl z • a7 <br />Lab Name: Green Analytical Laboratories, Inc. (970) 247-4220 FAX (970) 247-4227 Ana yses Required <br />Address: 75 Suttle Street, Durango, COS 1303 <br /> Colle ction Miscell aneous Pre serv ative (s) <br /> <br /> >" O J <br /> y <br />~ <br />P <br />' C, <br />9 <br />EJ <br />ti <br />..i <br /> <br />T <br />Sample ID Dale Time S, ° ^ ~ a; •o ~ Comments <br /> ~ Q, ~ <br />T m ° <br />° - <br />_ <br />'v: ° <br />'L <br />a <br /> U F <br />K (~ w .ti w 7 v ~ J <br /> <br /> U ~ FL ,Z rn .7 x x x z O 7 <br />S C2 tz -1.~- W <br /> -,2 _ ~ N tr r, ~ l <br />3. <br />4. <br />5. <br />6. <br />7. ( <br />t ~ <br />8. [ <br />~~ <br />t <br />10. , <br />r <br />Relinquished by: Da[ : -. Tipte <br />/ Received by: ~_ Dat :,L ~ Time <br />Relinquis y: D te: T <br />ime: Received by: Date: Time: <br />* §ampl~ct: [ ]Return [ ]Dispose [ ]Store (30 Days) • • <br /> <br />