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CHAIN OF USTODY RECORD Laboratory Sample Numbers (ACZ Us tly): f f PO <br /> Name to Appear on Report and Invoice: cc: (Report (Invoice) to: (circle one or both) <br /> ACZLaboratorles, Inc. <br /> 30400 Downhill Drive VP !le ctr ..d <br /> Steamboat Springs,CO 80487 <br /> r'' ? Rd el <br /> (970) 879-6590• (800) 334-5493 Attn: t'? c /,�. Tel: "' .. 15 Attn: "0g5e' Tel: ::<. J ;_;tt ,ra <br /> Project or P.O.# ANALYSES REQUESTED <br /> ` REMARKS <br /> Shipped Via: FED X UPS Hand Other-- U <br /> SAMPLE IDENTIFICATION DATE TIME Mme <br /> tP <br /> M G <br /> NIC <br /> • ^ .. 5l• <br /> V­­ <br /> Mad Options: SW(Surface water)•GW(Ground water)•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. ��'Nw.fir✓ + } �f`/ � 'f {' `I� <br /> Proper charges will be assessed. (ALt{ <br /> (A)Long-tern storage (8)If Sample Is Non-Hazardous (C)If Sample Is Hazardous j t # 7/ {,�• <br /> Hold until (date) 1) Local Disposal 1) RCPA-Perrclitted Facility <br /> for future analysis. 2) RCRA- Permitted Facility 2) Return to Client ! 1 <br /> 3) Return to Client — <br /> RELIN ISH D : (S GNATURE) DATE TIME - ..RECEIVED BY: ( SIGNATURE) DATE TIME P GE # <br /> °7 <br /> White-Return w/sample Yellow-Return w/sample Pink-Return w/sample Gold-Keep for your records <br />