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~ CHAIN OF CUSTODY CO Labiy s~ Nude (Ate O~ L~ S sf r cr-'~ ~-~--_- CuC w ~ ~ ~ `, <br />a <br />i <br />1 <br />i <br />4I <br />7 <br />0 <br />7 <br />0 <br />0, <br />J ~ <br />t' <br />~I <br />J <br />'I <br />~~ <br />~~ <br />a <br />c <br />0 <br />0 <br /> <br /> <br />ACZ Name to Appear on Reparl end Invoice: oc: (Report) - (Invoice) lo: (circle one or both) <br />SFCu~ ~ ~,.,~~,n~/ ..~i,c <br />Laborelarles, Inc. <br />7W000ovmhillDfive <br />Sleertt6oal Sprlnpe, CO 90487 <br />(910) 979-8590 • (9001 334.5193 N7o `~ rn nn ~ /c ~ <br />tai ~ ~//•^] ~/ovr o 8os~ S- »3,Z <br />Ann: f~r1~.~ ffifr.M ~H Tet:~jo) ~6.. yuro AtFn: ~~ ~jol~l _ aY ol: <br /> <br />ProleclorP.O.N ~o%o~ ~~, ANALY SES REQU ESTE D <br />1 r~~+ 7 <br />S•~~OR profrL +~ //v~fJ ~O~J-~/ <br />~ <br />Q ~ ~ <br />i ~ <br />H M ~ <br />,St REMARKS <br />ihlpped Via: FED X_ UPS._F1and_ Other $ ~s` ~ ~' <br />r$ <br />iAMPLE IDENTIFICATION DATE TIME MS°ar"p°. ` i~ e <br />W- 3.5 y o 6 ~ 7v c% - 'Hwyw e <br />w- - 3.0 67 9 ua ac k. <br />Mw- - 6 , vu r ' <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />YWIa Optlorr• Sw (Surhu »,1M • 6W (Ground waleQ ~ vrrY (Westeweler) • o'w (Orin4kq ~ralert • SL 151udge) • SOIL • OtL • Other (Specify) COMMENTS <br />~. <br />SAMPLE DISPOSAL OPTIONS - Pleesr compfele eecllon A, or choose ans opfbn Irom seclhyns BAND C. <br />propb cherpM wIN M eusessd. _ <br />nP/ ~o~ ~ ~S L/r-15 <br />f <br />!/y Lonp•Nfm elorepe <br />iotd uMN (dale) <br />~;~ ;NMO s^_t~•I.. <br />_._ /B) !/ SempH le Non•H.uerdaus <br />I) Local Diipoae! <br />2) RCRA - Permitted Facility <br /> <br />9) Relwn to Client (C) N Semple h He:erdoue <br />1) FiGRA•Pelmltted Facility <br />~ Re1um to CIbM <br />~EUNQUI HED BY: SIGNATUR E) DATE TIME RECEIVED BY: (SI GNATURE) DATE TIME PAGE Y <br /> i l6/U r ~ >a-- 3~ ~v/~ G ~ ~-_ <br /> ~' `~. OF <br /> <br />Wme -Homo w, s•my~~ ~a~~.... nvw... ,.r • ~•yic rn~n Homo n. ae myia <br />uoia - neap rar your reCOros <br />