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CHAIN OF GVTODY RECORD Laboratory Sample Numbers (ACZ Use OW Z— FCOC# 8 9 2 <br /> Name to ppear on Report and Invoice: cc: (Report) - (Invoice) to: (circle one or both) <br /> ACZLaboratories, Inc. ' <br /> 30400 Downhill Drive <br /> Steamboat Springs, CO 80487 1 <br /> (970) 879-6590• (800) 334-5493 Attn: Tel: Attn: Syl &L diviTel: <br /> Project or P.O. 71# C Woo- <br /> ANALYSES REQUESTED <br /> W REMARKS <br /> Z <br /> Shipped Via: FED X__UPS—Hand—Other 0 <br /> SAMPLE IDENTIFICATION DATE TIME I Sample <br /> Matrix <br /> 711 <br /> � .b <br /> *Matrix Optlons: SW(Surface water)-GW(Groundwater)•WW(Wastewater)•DW(Drinking water)•SL(Sludge)•SOIL•OIL•Other(Specify) COMMENTS <br /> SAMPLE DISPOSAL OPTIONS-Please complete section A, or choose one option from sections B AND C. Oaq <br /> ✓L' <br /> Proper charges will be assessed.(A)Long-term storage (B)H Sample Is Non-Hazardous (C)If Sample is Hazardous l/ f C o/�/ <br /> L.o�'� <br /> Hold until (date) 1) Local Disposal 1) RCRA-Permitted Facility <br /> for future analysis. 2) RCRA-Permitted Facility 2) Return to Client <br /> 3) Return to Client <br /> RELIN ISHED BY: (SIGNATURE) DATE TIME REC VED BY: ( SIGNATURE) DATE TIME PAGE# <br /> OF <br /> White-Return w/sample Yellow-Return w/sample Pink-Return w/sample Gold-Keep for your records <br />