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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): L-~`~(O~~ coca 15 3 61 <br /> <br />~~ Name to Appe Report ~nd~ Invoice: cc (Report) - Invoice) to: (circle one or both) <br />Laboratories, Inc. <br />3040 <br />hil <br />D G ~ ~ <br />own <br />0 <br />l Drive <br />Steamboat SprM <br />CO 80487 <br />s <br />`~ ~~- <br />g <br />, <br />(970) 879-6590 • (800) 334-5493 Attn: Tel• .. Attn: Tel ~. 7 <br /> <br />Project or P.O a Z~O~" A NALY SES R EQU ESTE D <br />~'~~~3d <br />~ ~' d' W <br />~ <br />RE <br />EIV <br />D REMARKS <br />Shipped Ya: FED X_ UPS_Hand_Other $ ~Ir 1 ~• 3t3 <br />SAMPLE IDENTIFICATION DATE TIME Sampa <br />Matnz <br /> Ot ~ f <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />• MaVrx Optiom: SW (Surface water) • GW (Ground water) • W W (Wastewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Speciry) COMMENTS <br /> <br /> <br />SAMPLE DISPOSAL OPTIONS -Please complete section A, or choose one option from aecdona B AND C. <br />Proper charges will bs assessed. /~~~""" _" <br />~~~` v <br /> <br />~ <br />~ <br />(A) Long-term storage <br />Hold until (date) <br />for future analysis. (B)1! Sample la Non-Hazardous <br />t) Local Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client (C) If Sample Is Hazardous <br />t) RCRA-Permitted Facility <br />2) Return to Client / /i _ ~~~~f <br />~6fGtiltsGQi~`~/%' `--~ <br />RELINQUISHED BY: (SIGNATURE) AT <br />D <br />E TIM <br />E RECEIV BY: S ATURE) DATE TIME PAGE a <br />~ A~ <br />p <br />{/ <br />V <br />7 /'/O r <br />~ V ~ ~v <br /> OF <br /> <br />White -Return w/ sample Yellow • ReWrn wl sample Pink -Return wl sample Gold -Keep for your records <br />