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CHAIN O STODY RECORD Laboratory Sample Numbers (ACZ Us ): L C <br /> 5410 <br /> ACName to Appear on Report and Invoice: cc (Report) (Invoice) to: (circle one or both) <br /> Z Laboratories, Inc. �"'�'` °� <br /> 30400 Downhill Drives`may f fkemont Pass hf J' Zia <br /> Steamboat Springs, CO 80487 Cfir»a x c o d CO 60//7-- <br /> (970) 879-6590• (800) 334-5493 Attn:��a Tel: Attn: So Tel: 303 g, GlSS <br /> Project or P.O. # ANALYSES REQUESTED <br /> JS IBO 43(?) REMARKS <br /> a <br /> Shipped Via: FED X V UPS Hand Other_ 0L) <br /> SAMPLE IDENTIFICATION DATE TIME Sample <br /> w <br /> Matnx <br /> s W -3 51J1 q <br /> L✓' �c� /3:� 5W <br /> •Matrix Options: SW(Surface water)-GW(Groundwater)•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 • ,ee_C©✓t7i&Ct <br /> p p o s B AND C. S <br /> Proper charges will be assessed. 11511- O/-' S <br /> (A)Long-term storage (B)If Sample Is Non-Hazardous (C)If Sample Is Hazardous <br /> Hold until (date) 1) Local Disposal 1) RCRA-Permitted Facility <br /> for future analysis. 2) RCRA-Permitted Facility 2) Return to Clientle <br /> 3) Return to Client /I Q U�V <br /> R QUISHE BY. (SIGNATURE) DATE TIME RECEIV D Y: ( SIGNATURE)) DATE TIME PAGE # <br /> J5 ��y o.' s <br /> OF <br /> White-Return w/sample Yellow-Return w/sample Pink-Return w/sample Gold-Keep for your records <br /> i <br /> I� <br />