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CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): ~ ;- " ' '\ <br />! 1 1. COC /! 7 $ 2 2 <br /> <br />ACZ Name to~ppear on Report a~nvoice: ~~~ cc: (Report) - (Invoice) to: (circle one or both) <br />~" `~`"`~`" <br />Leboratorles, Inc. <br />30400 Downhill Drlva <br />Steamboat S <br />rin <br />CO 80487 <br />s <br />p <br />g <br />, <br />(970) 879.6590 • (800) 334-5493 Attn: Tel: - Attn: Tel: <br /> <br />Project or P.O. # A NALY SES REQU ESTE D <br />`r ~ REMARKS <br />Shipped va: FED X_ UPS_Hand Other $ <br />SAMPLE IDENTIFICATION DATE TIME Mempe :` ~./ Ga....~ <br />-T~_ w S ,S o <br /> b Sw ~ 7 a <br /> - ~.S w ~a <br />7 -X )iyo S~ 19,6 ,y 6 <br />T- ago ~ r i ~ a <br />GS- o!b 6w <br /> av ~ w <br />- ~~ <br />Lc1 - 6~ ~ <br /> ~~ <br />• Matrbr Options: SW (Surface water) • GW (Ground water) • ww (walteweter) • OW (odnkinp wafer) • Sl (Sludge) • SOIL • OIL • Other (Specly) COMMENTS <br />SAMPLE DISPOSAL OPTIONS -Please complete ssctlon A, or choose one option from seetlons B AND C. <br />Proper r:hargss will he assessed. <br />(A) Long-term 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) Retum to Client (C) M Sample /s Hazardous <br />1) RCRA-Permitted Facility <br />2} Return to Cliem <br />RELINQUI HED BY: (SIGNATURE) D TE TIME RECEIVED BY: (S IGNATURE) DATE TIME PAGE b <br />r <br /> ~~ <br /> s-3~ <br />White -Return w/ sample <br />Yellow -Return w/ sample <br />j PiAC- F~urn w/ sample <br />Gold -Keep for your records <br />