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IYI <br />INTEtt-MOUNTAIN LABS <br />Inter-Mountain Laboratories, Inc. :::. ' . --CHAIN OF' CUSTODY'RECORD - ° <br />Sheridan, WY and Gillette, WY This is;a LEGAL DOCUMENT. All shaded fields must be comoleted ~ '~ `~ ~^_ ~-h ~:> ~' <br />Client Name ~ ~ ~ /~~~ ~. ,~ ~, ~ ~ r <br /> <br />r ; ,~ _`''y <br />„, ~- h <br />:. <br />Pro'ect Identi£cation <br />1 ~ '~•: °j <br /> <br />Sampler (Signature/Pr•inted)~ <br />~. <br />~ ~. ~Ay g w,+' <br />Telephone # <br />• <br />' t , <br />,' _ ~~_ - <br />..: . .... <br />1 <br />+ <br /> <br />Report Address r_ <br />,_. _ <br />,~; <br />J ° .} ."' <br />Contact Name and Email <br />..~' <br />-~ ANALYSES /PARAMETERS <br />, , <br />f <br />.j :, <br /> <br />' , <br />~ ; _- ' <br /> <br /> <br />•~ - . -. <br />~ Voice <br />~ - <br />Invoice Addre"ss FAX -_" ° <br />- `, .Purchase Order # Quote # _ <br />W LAB ID DATE TIME '' SAMPLE # of REMARKS <br />~ (Lab use only) SAMPLED IDENTIFICATION Matrix Containers <br /> ~ <br /> <br /> <br /> <br /> <br /> <br />~. I t ~ i <br />F <br /> <br /> <br />/ <br /> <br />.$/ w f ?~ ~ <br /> <br /> <br />_ <br /> <br /> <br />in, `t :., <br />~, <br /> <br />iF <br />, <br />~ r <br />!F" <br />_~ ,; k iii %1) %~ j (/~ '^ z~rt.- _ <br /> <br /> <br /> <br /> <br /> <br />°/ ~ <br /> <br /> <br /> <br /> <br /> <br />: <br /> <br /> ~, _ <br /> <br /> <br /> <br /> <br /> <br /> <br /> f <br /> <br /> <br /> 'r <br /> <br /> ~ ~~ <br /> ~. <br /> a. ~ <br />i <br />:, . J <br />. •i <br /> <br />~ .~ <br /> <br />~ <br /> <br /> <br />., ~ f <br /> <br />; <br />4.~j ~ ' <br /> <br />... <br />.. <br />^ UPS Water WT ,Check desired service Compliance Monitoring ? `°Y;! N ''t '~ ^ '' -"` t J ,;- <br />^ _Fed Express Soil SL f7-:Standard turnaround Program (SDWA, NPDES, ...) ~ - <br />=0' US Mail Solid SD ^ RUSH - 5 Working Days PWSID /Permit # ~ ~ ~~" i ~,.; I t ~r~,, i ,< s,~ , <br />^ Hand Carried Trip Blank TB ^ !URGENT - < 2 Working Days Chlorinated? ~ YIN J F <br />^ Other Other OT Rush & Urgent Surcharges will be applied Sample Disposal: Lab ` , s Client j /Y)iC`%' ' <br />iv7?ia-.wruv:.L,v i.ai3a ei.-;arks- ivc• <br />Rev 4.3 <br />