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• <br /> CHAIN OF CUSTODY RECORD LaboratoryICA Sample Numbers (ACZ Us ly): � S F� 10645 <br /> Name ppear on Report and Invoice: cc: (Rep rt) - (Invoice) to: (circle one or both) <br /> ACZLaboratorIes, Inc. <br /> 30400 Downhill Drive y �y , <br /> Steamboat Springs, CO 80487 Attn: Tel: -- Attn: Tel: - <br /> (970) 879-6590• (800) 334-5493 5 <br /> Project or P.O. # ANALYSES REQUESTED <br /> a � <br /> (,pI 0a � � REMARKS <br /> Shipped Via: FED X . UPS Hand Other 0 <br /> Sample � <br /> SAMPLE IDENTIFICATION DATE TIME Matnx• 'd <br /> )00 <br /> *Matrix Options: SW(Surface water)•GW(Groundwater)•WW(Wastewater)•DW(Drinking water)•SL(Sludge)•SOIL-OIL•Other(Specify) COMMENTS MW <br /> SAMPLE DISPOSAL OPTIONS-Please complete section A, or choose one option from sections B AND C. �1� 1�1 <br /> Proper charges will be assessed. <br /> (A)Long-tern storage (B)If Sample Is Non-Hazardous (C)N Sample Is Hazardous <br /> Hold until (date) 1) Local Disposal 1) RCRA-Permitted Facility meta L/ <br /> for future analysis. 2) RCRA- Permitted Facility 2) Return to Client <br /> 3) Return to Client <br /> RELINQUISHED BY: (SIGNATURE) DATE TIME RECEIVED 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 />