REV101057

• Permit No: M1977215
• IBM Index Class Name: Revision
• Doc Date: 1/20/1999
• Doc Name: FAX COVER
• From: DMG
• To: ALLEN SORENSON
• Type & Sequence: TR5
• Media Type: D
• Archive: No

CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (AGZ Use Only): ! ~ /~! Z ~`
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Name io Appear on Report and InvoiceName Appear on Report and Invoice: cc; (Report) - (Invoice) :o: (circle one or bo:h)(
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Laboratories, Inc.
2773 Do ~ ~
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wnhill Drive
Steamboat Springs, CO 80487
[phone] • [phone] T _Z ~ •J.U GO vQOZ.o'
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Project or P.O, t! "Z2 Z A NALY SES REQU ESTE D
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REMARKS
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Shipped Via: FED X` UPS_Hand_Other_ ~ ~i', I
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SAMPLE IDENTIFICATION DATE TIME 1 Mall: a ±~~ I " r
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• MalriN Op;ions_ SW (Surface walerJ • GW (Ground walerJ • K4N (Wasle~~va'er) • DoY (Drinking walerJ • SL (SWOge) -SOIL • OIL • Gher (Speedy) COMMENTS
SAMPLE DISPOSAL OPTIONS - Please complete sect/on A, or choose one option from sections B AND C
Proper charges will be assessed.
(AJ Long term storage
Hold unfit (date)
for future analysis. ll Sample !s Non-Hazardous (C) h Sample is Hazardous
ocal Disposal ; i) RCRA-Permitted Facility
2) RCW1-Permitted Facility i 2) Return to Client
3) Return to C(ienl
REL1I~lQUISHED BY; (SIGNATURE) DATE i T1ME j EIVE BY: (S IGNATURE) DATE TIME PAGE IY
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