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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): ~ ,_ '' ' <br />~ 1 1. COC q '] $ Z 2 <br /> <br />~~~ Name to ppear on Report and Invoice: cc: (Report) - (Invoice) to: (circle one or both) <br />~`~~' h <br />~"~`~``~`" ~~`, <br />Laboratories, Inc. ~ <br />~~ <br />30400 Downhill Drive <br />t S <br />CO 80487 <br />St <br />b <br />i <br />oa <br />pr <br />ngs, <br />eam <br />(970) 879-6590 • (800) 334-5493 Attn: ~~ f (zs Tel: ~ - Attn: Tel: <br /> <br />Project or P.O. N A NALY SES REQU ESTE D <br /> REMARKS <br />Shipped Via: FED X_ UPS_Hand Other ~ <br />SAMPLE IDENTIFICATION DATE TIME Sample <br />Matnx ~ ~ J,~ GD ~~l <br />T/-1- ~ ~ w S p . S ~v <br /> b 5w ~ 7 b <br /> - ~ w $a <br />7 ~ ~ lino Sw lq.6 ,Y 6 <br />T- ago ~ r i ~ a <br />~ - lole Gw <br /> av oww <br /> I~ 6~ <br />(.,cJ - 6La y <br />- C~ u-?' <br />• Matrix Options: SW (Surface water) • GW (Ground water) • vnv (Wastewater) • DW (Drinking water) • SL (Sludge) • SOIL • OIL • Other (Speciry) COMMENTS <br />SAMPLE DISPOSAL OP710NS -Please complete section A, or choose one option /rom sect/ons B AND C. <br />Proper charges w/ll be assessed. <br />(A) Long-temr storage <br />Hold until (date) <br />for future analysis. (B) n Semple !s Non-Hazardous <br />1) Local Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client (C) I/ Semple Is Hazardous <br />1) RCRA-Permitted Facility <br />2) Return to Client <br />RELINQUISHED BY: (SIGNATUR E) D TE TIME RECEIVED BY: (SIGNATURE) DATE TIME PAGE k <br />- 7 O <br /> oy <br /> S% 3 - <br />White -Return w/ sample <br />Yellow -Return w/ sample <br />j PiWC- ggNrn w/ sample <br />Goltl ~ Keep for your records <br />