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J <br />V <br />V <br />?d <br />Analytica Chain of Custody Form <br />12169 Pennsylvania St 4307 Arctic Boulevard 475 Hall St 5438 Shaune Drive <br />Thornton, CO 86241 Anchorage, AK 99503 Fairbanks, AK 99701 Juneau, AK 99801 <br />ANALY FICA (303) 4698868 (907) 258-2155 (907) 456 - 3116 (907) 780.6668 <br />(303) 4693254 fax (907) 258-6634 fax (907) 456-3125 Fax (907) 760.6670 fax <br />Chain of Custody No: <br /> <br />74904 <br /> <br />Client Name & Address: Public Water System (PWS) lD#: <br />r? <br />i ? t N <br />• <br />P 0 Quote ID: LGW <br />-Z> TZ <br />•?S <br />a? rojec <br />ame <br />rgfi7- s 3 0 <br />?- ? <br />- ?Jo5i3p <br />10 <br /> <br />S S4 - -lo- Z(-5 <br />313 , <br />E <br />) <br />- <br />?w".V,'t co g0 Z O-3 <br />i? Aocount #: Cash Credit Card <br />Report to: <br />J. -C • Is F -11 I invoice to Name & Address: <br />I <br />A <br />S <br /> DIz <br />( <br />- <br />Phone No: <br />3©3-Sc6-3.s?+r7 x g10k Standard Expedited (4icdamPrior mmarhadonrwulm) Zl S <br />i313 skeiw.s -S <br />Fax No: (? aan?v -Y vrlr s"A.y4w- <br />D <br /> <br />E-mail' C&V" lp? v s-(7. , cc . it <br />Requested Due Date for Results: 44+(A <br />! <br />Special instructions/CQm nts J, K <br />C &;,r se, r" u"& p o, or Contract No: <br />/j/qf <br />i0bti = C) r/ , SOQ' (Tot( / Requested Analysis/Method <br />f}Z SBar re5err - w.ttk: k -4 /103 -c /?d? .nt <br /> <br />Kit Prep/Shipping Charge: $ <br />r m <br />c <br />i o <br /> <br />V <br />m <br />d <br />`w n <br />- e7 <br /> <br /> <br />Time <br />Date <br />l <br />d <br /> <br />z <br /> <br />v <br /> <br />3 't <br /> <br />-.. e <br /> <br />CL U. <br /> <br /> <br />2 <br />Client Sample identification / Location e <br />Samp <br />Sampled _ <br />3 <br />D <br /> <br />? <br />o LL <br /> d ? <br />I , <br />Q i <br /> 0 1 X 'K x ? Al <br /> it 0,30 <br />5w- X <br />Mw_ ./ ?t r2 ?? X )c x K <br />Rtakw' s ? ; i` 1-3/5 i. X' K X K ? <br />? <br />W <br />t <br />1j it 1'345 t% <br />x <br />?C <br />X x <br />- <br />/ <br />9 <br />L <br />SLJ - I? PL ;% Ii M-00 r' X x >/ IV <br />Sw - 05 It 1-30 x x X ,N <br />S W - ? o1n ,? I' 145a '? 1 X Al <br />foi,west ISao <br />eli q ished b Date Time Received by: Date Time <br /> RES ) . SS Condition of THO ANC JNU FBKS <br />Relinquished by. Date Time Received b : Date Time, Custody Seal?: <br /> initieled.Sy <br /> <br />Relinquished b : Date Time Received b : Date Time TemplLoc: <br /> Thermo ID#; <br /> <br />Name of Sampler: (printed) B?`S't/ 11) 1( RI) Shipped Via: <br />Version 2.0