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CHAIN OF STODY RECORD Laboratory Sample Numbers (ACZ Use M COC# 11724 <br /> Name to Appear on Report and Invoice: cc: (Report) - (Invoice) to: (circle one or both) <br /> ACZLaboratorles, Inc. I d v co <br /> 30400 Downhill Drive / <br /> Steamboat Springs, CO 80487 i 10 80 ��• <br /> (970) 879-6590- (800) 334-5493 Attn: U�.� ����U Tel: y 4/g(Cay—Attn: UZiCie Tel U <br /> Project or P.O. # ANALYSES REQUESTED <br /> C cc REMARKS <br /> J'51MG N'7> z <br /> Shipped Via: FED X AUPS—Hand—Other 0 <br /> w <br /> SAMPLE IDENTIFICATION DATE TIME I Sample ' <br /> } Maftn e <br /> *Matrix 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. � <br /> Proper charges will be assessed. C/ <br /> (A)Long-tens storage (B)If Sample Is Non-Hazardous (C)!f Sample Is Hazardous //P?aVC& <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 /> RELINQUISHED BY. (SIGNATURE) DATE TIME REC VED BY/9( SIGNATURE) DATE TIME PAGE# <br /> Af <br /> OF <br /> White-Return w/sample Yellow-Return w/sample Pink-Return w/sample Gold-Keep for your records <br />