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CHAIN Or .:LISTODY RECORD Laboratory Sample Numbers (ACZ UsLl~,ly): ~l `j 3 3s cow ,~ ~ 1 3 6 2 <br />Name to Appear on Report and Invoice: cc: (Report) - (Invoice) to: (circle one or both) <br />CZ Laboratories, Inc. <br />30400 Downhill Drive ~~ 1 <br />Steamboat Springs, CO 80487 <br />(970) 879-8590 • (800) 334-5493 Attn: J~ 5 ~~ Tel: - gr~ Attn: Tel: <br />Project or P,O. M ANALYSES REQUESTED <br />W ,,~ REMARKS <br />d <br />Shipped va: FED X_ UPS_Hand Other <br />SAMPLE IDENTIFICATION DATE TIME Sample ~ ~ p~ ~.~ <br />Matnz <br />$ 1 030 (ate - 6 4~0 <br />7 (" Gw C o. S ~ D <br />! ~ .~ Y o <br />~ /S c,~ - 0 9 7 G <br />7 7 Sas . cam, o, 7 7'70 <br />~° y 5 r c.~ l o, 3a o <br />o ~~.s 7o C~ <br />• Mavlx Options: SW (Surtace water) • GW (Ground water) • W W (Wastewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Specity) COMMENTS <br />SAMPLE DISPOSAL OPTIONS -Please complete sect/on A, or choose one opt/on from sect/ons B AND C. <br />Proper charges will be assossed. <br />(A) Longterm storage (B) !I Semple Is Non-Hazardous (C) I! Semple Is Hazardous <br />Hold until (date) 1) Local Disposal 1) RCRA-Permitted Facility <br />for future analysis. 2) RCRA -Permitted Facility 2) Return to Client <br />3) Return to Client <br />RELIN~UISHE BY: (SIGNATURE) D TE TIME RE D BY: SIGNATURE) DATE TIME PAGE ft <br />.~! ,'S <br />OF/ <br />T <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Gold -Keep for your records <br />