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HAZEN RESEARCH, INC. °~ <br />4601 Indiana St. • Golden, CO 80403 <br />FEN Tel.: (303) 279-4501 • Telex 45-860 <br /> <br />CHAIN OF CUSTODY RECORD <br />Prof No. Protect Name <br />.~~ ~zS~ <br />Samplers (Signature) <br />~I <br />`~ <br />Sta. No. Date Tlme omp Grab Station Location No. of <br />Containers ''-" Remarks <br /> -c~~~ ~ <br /> -Z u'v!F <br /> <br /> <br /> WO#BOF# ^__^~--- <br /> Present Y-(N~ intact Y/N <br />l <br />S <br /> ~ <br />ea <br />s <br />Pres Y/N/I~ Hd Sp Y/N/~ Loc~ <br />BY f <br />~A' <br /> ~ <br />(i - <br />Temp (C)'~j0 Container t <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />e n 1 by: (Signature) <br />~U MAC -- Daterilme <br />~~ ~3v ReceNed by: (Signature) <br />~/'.- ~/~- Relinquished by: (Signature) Datei'Rme Received by: (Signature) <br />Rellnqulahed by: (Signature) DeteRime Received b'Y: (Signature) Relinquished by: (Signature) Date/Tlme Recalved by: (Signature) <br />pellnqulahed by: (Signature) Dats?Ime ReceNed for laboratory by: <br />(Signature) Remarks: <br />Okttlbutbn: Whbe Copy • Ship Whh Semple; Cenery Copy - Laboratory Copy; Pink Copy • Oriplnetor'e Copy <br />