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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): ~ ~ ~` % ~ cQc s 1536.3 <br /> <br />ADZ Laboratories, Inc. <br />30400 Downhnl Dr1ve <br />Steamboat Springs, CO 80487 <br />(970) 879.6590 • (800) 334-5493 Name to Appear on Report and Invoice: cc (Repo - (Invoice) to: (circle one or both) <br />~e"'"s~' /1'"'"' ~. <br />~R~?Fn..,.e S~v~..f •• ~ : dl / <br />~+~ ~TwNNirn lift 9y/off !' ~ <br />Attn:,~~A~ rox el:y~ yP3_g7~ Attn: Tel: _ <br />Protect or <br />P.O. N z(~g A NALY SES REQU ESTE D .. <br />~/ <br />/Suuoo /7~., ~ Q <br />W REMARKS <br />Shipped Via: FED X_ 11~S_Hand_Other $ ~ .. t <br />SAMPLE IDENTIFICATION : DATE TIME see We : ~ ".y~ • <br />_ <br />/0 K <br />O <br /> ,...0 Zl~ <br /> <br /> <br /> ~~ <br />-• <br /> <br /> <br /> <br /> <br />• Matrbc Optloru: SW (Surleca water) • GW (Ground water) • ovw (Wastewater) • OW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Specrly) COMMENTS <br /> <br />SAMPLE DISPOSAL OPTI6NS -Please complete seMlon A, or choose one option hom sections BAND C. <br />Propsr charges will be assessed. // <br />~„ ~ ~- 5'rrfj,~yta.~ <br />Tom <br />(A) Long-farm storage <br />Hold until (date) <br />for future analysis. (B) Il Sample /a Non-Hazardous <br />t) Local Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client (C) !t Sample Is Hazardous <br />1) RCRA-Permitted Facility <br />~ Retum to Client <br />RELINQUISHED BY: (SIGNATUR E) DATE TIME RECEIV BY: (S IGNATURE) DATE TIME PAGE p <br /> /, 9 C C/' /o c., l <br /> OF <br /> <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Gold - Keap for your records <br />