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<br />Accu-LaUs Research, Inc. <br />9663 Table Mountain Drive Golden, CO 80403-1650 <br />(303 277-9514 FAX (303)277.9512 <br />CI1AfN OF CUSTODY AND SAMPLE TRANSMITTAL FORM <br />ALR Job p: <br />rmni n,•. r <br /> PLEASE FILL OUT COMPLEI-ELY. Bottle Size & Preservation Page ~ of _~_ <br /> BE SURE SAMPLE IDp MATCHES SAMPLE LABEL Total ~ <br />" <br /> <br />ALR <br /> <br />Use <br />Only <br /> <br /> <br />ale O( <br />CeNeetior. <br /> <br /> <br />ime OI <br />Collectrn <br /> <br /> <br />ample <br />Type <br /> <br /> <br /> <br />ample Idenlilicalion Number <br />of <br />Bottles <br />Per <br />Sample > ~ , <br />S C <br />~ ~ . <br />~ Analyses Requested <br />~ (Attach Additional Pages II Necessary) <br /> '1 (~s 035 vV 9`1078 ~oI 1 ~ ~ ~ T /-lv~,o <br /> n n 1, rr I ~ Cd G.. ~, e,~e ,M <br /> ~L rr \ rr ~ ~/ f / <br /> <br /> <br /> <br /> <br /> <br /> I <br /> I - <br />Ilent Name L~ `r ~e/ /1 ~~ <br />lien! Contact ~ 'Pf (tor r¢porl) <br />lone 1~)~O7a•.3~a FAX 1~1 ~7a-33(o3 <br />iampler (Print Name1: <br />5~-Y <br />~mp)er (~~a~rel: <br />rject or PWSID <br />~eh:.;e Or~er~p:. <br />APPLICABLE REGULATION: <br />SDWA NPDFS <br />CWA RCRA <br />Other N/A _ <br />-S~Aa,(~ ~~) ~ I Nofily I-.ib o1 any special turnaround <br />~ n time or QA Requirements <br />ALR Contact <br />Remarks <br />1) ReNtlquished B . ~ /t~l <br />' Dale and Time R¢ veil <br />, \ <br />y <br />il,~ 'r'~~C~ <br />~~ p <br />u'~~ <br />Il ' hed Date and Time R¢celved <br /> <br />3) Relinq i ed By Date and Tlme Received for ALR By: <br /> <br />oic^ To: <br />