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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): 9 /(%~/~i <br />C <br />/ <br />[ <br />~ <br />( <br />D coc n 15 3 6 4 <br /> <br />~~~ Laboratorles,lnc. <br />30400 Downhill Drive <br />Steamboat Springs, CO 80487 <br />(970) 879.6590 • (800) 334-5493 Name to Appear on po an~nvoice: ~ cc. <br />~ <br />~ C ! <br /> <br />Attn: Tel• Attn: (circle one or both) <br />q~e) to <br />: <br />Report) <br />( <br />In <br />v <br />l `J <br />C• , ~O O 2 <br />Tel: <br /> <br />~ <br />Project or P.O. # ~1 1 O $ A NALY SES REQU ESTE D <br />~„~~ ~; h e <br />e~ Co 81/ = REMARKS <br />Shipped Va: FED X_ UPS Hand _Other $ • <br />SAMPLE IDENTIFICATION DATE TIME Sample <br />Matnx a <br />- a0T- / ~(~ <br /> <br /> <br /> <br /> .r <br /> <br /> <br /> <br /> <br /> <br />• Matrix Options: SW (Surface water) • GW (Ground water) • W W (Waztewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Speciy) COMMENTS <br />SAMPLE D/SPOSAL OP7TONS -Please complete sect/on A, or choose one option /rom sections B AND C. <br />Proper charges will be assessed. <br />(A) Long-term storage <br />Holtl until (date) <br />for future analysis. (B) It Sample Is Non-Hazardous <br />1) Local Disposal <br />2) RCRA - Permitted Facility <br />3) Return to Client (C) lI Sample !s Hazardous <br />1) RCRA-Permitted Facility <br />2) Return to Client <br />RELINQUI HED BY: (SIGNATUR E) DATE TIME RECEI D BY: (SIGNATURE) DATE TIME PAGE # <br /> C~ - ~ - 8 ~ l ,y <~v <br /> OFII <br /> ~L <br />`~j <br /> <br />White -Return w/ sample Yellow -Return w/ sample Pink -Return w/ sample Gold -Keep for your records <br />