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CHAIN OF CUSTODY RECORD Oratory Semple Numbers (ACZ Use Only): COC # '' <br />$~~ J <br /> <br />~~ Name to Appear on Reppo~rt and Invoice: : (Repo - (Invoice) to: (circle one or both) <br />glue 1(It,.r uict,• t btu cti~ <br />r.,., a r• L; r <br />Laboratories, Ina <br />30400 DownhAl Drive <br />Steamboat Springs, CO 80407 <br />(970) 879.6590 • (8001 334-5493 _ <br />}t" •~` Ott _l <br />41 ~ .- C C., ~ I b <br />'~~ - ~ , <. ~ hull Tel: ~S-~ 3 In Attn: ~ t r k r. Tel: g - 2 f~ p <br />Protect or P.O. # A NALY SES REQUESTED <br />}: -crr nli, r,,,,,~,. ~ <br />Jtr li C.rc..uJ••-~.~r. lurl~l ¢ <br />= ~ <br /> <br />s ~ REMARKS <br />Shipped Via: FED X_ UPS_Hand Other $ N ~ ~~ A <br />SAMPLE IDENTIFICATION DATE TIME ~r"~°, s /S~ 1~t~t~ Cu v Trlrt <br />3U-~Ivl `/ 6W 1 (.tud I~Ic,tt- (' Nic <br />3Z- 1-. '~~i EJW ! SP( rltur <br />'I- ~ ~ Gw f <br />z~l-gt~ti ~ sw 1 x <br />~3-Ew1 5 6~N ~ <br /> <br /> <br /> <br /> <br /> <br />• Metrbt optloro: sw (Surteco water) - Gw (OrourW water) • W W (INasteweter) • DW (Drinklrp water) • SL (slWpa) • SOIL • OIL • omer tsp«nyl COMMENTS <br />SAMPLE DISPOSAL OPTIONS - Plsasa complete sseflon A, or choose ons optbn Irom aecGona BAND C. <br />I#oper charysa will bs aswaasd. <br />(A) Long-tam storeys <br />Hold until ~(rr., 3(L(date) <br />for future one a. J H Sample li Noo-Hazardow <br />1 Local Disposal <br />2) RCRA -Permitted Facility <br />3) Return to Client ; : J // Semple k Hazardous <br />CRA-Permitted Facility <br />2) Return to Client <br /> <br /> <br />tea' <br />RELINQUISHED BY: (SIGNATUR E) DATE TIM E REC ED BY: (S IGNATURE) DATE TIME PAGE # <br /> <br />12 <br />~ vo ~,,: <br />y ~ ~ ~ <br />~~7 •~ - <br /> r -~ .. OF <br /> <br />While • Retum w/sample Yellow -Return w/ sample Pink • ReWrn w/ sample <br />Gdd -Keep for your records <br />.s <br />1 <br />•~~ d <br />