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CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES AGREEMENT ** <br /> Evergreen Analytical Laboratory PageAof I <br />CLIENT INFORMATION Quality Data on TimeO <br />LL <br />Mail Original Report to: <br />Attn _ ?9 Q ?i??C=-r`_ ? 4036 Youngfield St. <br />Colorado 80033 <br />Wheat Ridge, Report Results by: (Date)' <br /> <br />Address / \ 30 <br />3) 425-602 Standard 2 working weeks <br />ttW <br />city <br />+ E V ©o 19 FAX (303) 425-6854 <br />State Zip UST Analyses per Fee Schedule ? <br /> <br />Tel# r0'3--Oif-& ? # (877) 737-4521 <br />E-mail \Mp_ C)W%dV.4_ e-mail info@evergreenanalytical.com *Rush: ? less than 24 hrs,150% ? 1 - 2 work days, 100% <br /> <br />REPORT ALSO BY ? FAX *PDF ?, VA <br />? EDD FAXED CONFIRMATION OF SAMPI_%QCEIPT REQUIRED? ? YES ? 3 5 work days, 50% ? 6 - 9 work days, 25% <br />l <br />h <br />d <br />' <br /> Subject to surcharge & exceptions note u <br />e. <br />d in fee sc <br />e <br />nCrumi l?r1muIVIAIUL:ihAMJ U YtJ I <br />Mail Invoice to: MATRIX ANALYSES (check anaylsis) For Laboratory <br />A Use Only <br />ttn <br />Address <br />2 <br />WO.# <br /> <br />City State Zip ; U <br />R) <br />B.O.F. # <br /> <br />Tel # Fax # co <br />N <br />CIS (O)____J_ <br />ProjectID# '?UtIIr_ mall a1+ m / <br />e <br /> <br />P. 0. Quote <br />`o c 2 m <br />a mp. <br />T <br />Temp. °C /, Ice_ <br />Sampler <br />?(G1 C^ <br />Es -0- d <br />.9.) o <br /> <br />O <br />Q <br />fo Seals PresentY / N / NA <br /> <br />NOTE: Identify Known Hazards Below 5 <br />? o <br />m"' - <br />'D d <br />CM Samples Pres. Y/ N/ NA <br /> <br />SAMPLE DATE 1 <br /> <br />`° 1- <br />0) ..? -4 <br /> <br />C; Headspace Y / N / NA <br />IDENTIFICATION SAMPLED TIME z ° oco o <br />35-r- Z. "71 111o5 'I V Fig Z1 1 I <br /> 9 ! <br />E I!, 1ACCA z d v s P <br />w'? ?. AW <br />? <br />d Y 1 <br />Ica -Z%I? ' d / d O ?' <br /> <br /> <br /> i <br /> <br /> <br /> <br /> <br />Does this analysis involve property transfer? ?Yes or M o Sample Fraction <br />Instructions: <br /> <br />** Important Note: See reverse side hereof for terms and conditions. <br />Relinquished b ;?(Stgn ture) Date/Time <br />05 Received by: (Signature) Date ime Relinquished by: (Signature) Date/'nme Received by: (Signature) Date/Time <br /> <br /> <br /> <br />