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G~N ~US~Y f~R bcil~ SIB NutJ~ (Ate t~ ~ ~ ~ t~- ~ ~ I~N 1~8 ~ <br /> Name to Appear on Report and Invoice: cc: (Report) - (Invoice) to: (circle one or both) <br />~ ~ rr• r SE(OR- ' ror a ~.+cur~ <br />Laboratorlea, Inc. <br />3040 <br />D <br />hill 4700 HLMuYv.s S ~I 3z/h, o <br />0 <br />own <br />Drive <br />Steamboat S <br />rin <br />s <br />CO 80487 owns 1; ' $ ~I II( S S 06 <br />p <br />g <br />, <br />(970) 879.6590 • (800) 934.5493 Attn: Tel: o Ann: Tel: <br />-~~p~M" ~~ ~ R7 ~7(,-'W'/0 c • 6 "2.7556 <br /> <br /> <br />ProJed or P.O. N A NALY SES REQU ESTE D <br />~~' Qd~78' - 003-0 ~ ~ REMARKS <br />ihipped Via: FED X_ UPS_Hand_Other ~ J <br />' <br />F <br />~ F / ~ ~~ <br />iAMPLE IDENTIFICATION DATE TIME Samps <br />Melnr< ~ 1 <br />V ~~ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />uevu Opliau: SW (Surface wafer) • GW IGrourM wafer) • WW (Wuteweler) • OW (Drinking wafer) • SL (Sludge) • SOIL • OIL • Olfter (Specny) COM MENTS <br />SAMPLE DISPOSAL OP7)ONS - Plseas complete asetlon A, or choose one opt/on from secf/ane B AND C. <br />PIOp1/ Ch1/yq Wlll bs /eNSeed. <br />A) Lonyfsrm storeys <br />cold unlit (date) <br />n h_11i_rfA_ AnaIVRIC (BJ Il Sample /s Non•Nererdoua <br />t) Local DISp0581 <br />21 RCRA -Permitted Facililv <br />3) Return to Client (CJ l! Semple Is NazeNoua <br />1) RCRA-Permitted Facility <br />2) Return to Client <br />3ELI HE IGNATUR E) DATE TIME RECEIVE BY: SI GNATURE) DATE TIME PAGE N <br />.~ l~ / /J v~- z~y ~- <br /> OF <br /> <br /> <br />N <br />I <br />O <br />V <br />_N <br />v <br />D <br />D <br />n <br />N <br />r <br />a <br />Q <br />0 <br />T <br />a <br />0 <br />~. <br />m <br />N <br />N <br />7 <br />n <br />V <br />O <br />V <br />I <br />N <br />N <br />F+ <br />Q~ <br />O <br />N <br />Wli~te ~ Roluin w/ sample Yellow ~ Return w/ sample Pink ~ Rewrn w/ sample Goltl ~ Keep for your recortls <br />