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J <br />~ CHAIN OF CU ~~v s~ Nubs (A~e u~ <br /> <br />3 <br />i <br /> <br />4I <br />J <br />U <br />A <br />A , <br />~ ~ <br />x' <br />~I <br />V <br />~~ <br />a <br />~~ <br />L <br />>> <br />a + <br />a <br />c <br />o i <br />a <br />0 <br />,~ i ;. . <br />STODY RECORD L~ > ~' ~.1~7 -p!_ Cu ' U <br /> <br />ACZ Name to Appear on Report and Invoice: oc: (Report) • (Invoice) lo: <br />$FCU/1 .~ k,,,a~„~l Sr,r ~ (circle one or both) <br />l.aboralorlee, Inc. <br />X0400 Downhill Drive <br />Steamboat Springs, C090497 <br />(970) 878.8580 • (900) 334.5483 <br />N Ton 1/1 r 1`7 <br />~i t ~~/~.n ~ <br />Attn: ~'[!n .~ !/a ~7Y.M n w _ <br />„ rr~y l7n ~ , /v <br />~/o~rr~q ROS~S-s`s3z <br />Tel:~j7a~ ~7e ._ 4u~iu Atkr. ~~ !fj-jD~a7.; - 4o Y q <br /> <br /> <br />l: <br /> <br />Pro(ecl or P.O. A No~i7awt ~~ ANALY SES REQU ESTE D <br />S'~coR ~iofrZr ~ /~017~-003_0 Z <br />Q ; { <br />N N ,'~ <br />~ ~ REMARKS <br />ihipped Vii: FED X_ UPS_Hand~ Other $ ~r` ? ~' <br />iAMPl.E IDENTIFICATION DATE T1ME M~°, ~ ~ ~ ~ <br />w- - 3.5 0 6 , 7v c ~ - Hay1ti+ e <br />w- - 3.0 67 Y uu ar.k - <br />P~w- - 6 ~ uo <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />YW~ Opllonc SW ISurhu w.>h • 6W (Oroimd water) • M1v (Wast~Ymteq • Ow (Orinkkp vrater) • SL (SIWge) • SOIL • Oil • Olhei (Spetifyl COMMENTS <br />•~~~~ <br />SAMPLE DfSPOSAL OPAONS • P/eess compute ssellon A, or ehooas ons optron r'mm ssetlons B AND C, <br />oropri cl,srpss rHU w sssssssd. <br />ne/ CvZr o ~e <br />I <br />R' ~S ~/~15 <br />!A) Lone•hnn wasps <br />void urNN (dale) <br />a luiura ru.dyoL• (B) I(Ssmpls Is Non•Husroaus <br />f I Local Disposal <br />21 RCRA - Permlged facility <br />9) Return to Cllerll (C/ h Semp/s !s Hareroous <br />t) ACRA-Permined Facility <br />~ Relum to Client <br />~ELINQUI HED BY: SIGNATUR E) DATE TIME RECEIVED BY: (SI GNATURE) DATE TIME PAGE 11 <br /> <br /> ~' ~ OF <br /> <br />rvm~ - ne•u~n .n wn~yie <br /> <br />,.~., ........~~.., ~,~Y~a <br />vvm nwp m. YeU. .000f05 <br />