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Analytica Chain of Custody Form <br />12189 Pennsylvania St 4307 Arctic Boulevard 475 Hall St. 5438 Shaune Drive <br />Thornton, 00 60241 Anchorage, AK 99503 Fairbanks, AK 9970t Juneau, AK 99801 <br />ANALYTICA (303) 469.8888 (907) 258-2155 (907) 456 - 3116 (907) 780-6668 <br />cxove ao (303) 4695254 fax (907) 258.6634 fax (9071458.3125 Fas <br />Page / of _ I <br />Chain of Custody No: 74106 <br />Cliet David Bird <br />Colo. Div. of Reclam. Mining & Safety <br />1313 Sherman Street, Rm 215 <br />Denver, CO 80203 <br />Report to: S'euK-P- <br />Phone No: 3c?j X`?- 3? ? 7 % <br />Fax No: 3C 3 -?'3Z- 8"It <br />/ <br />E-mail: da,14 W.114 . Sta f' _ co - KS <br />Special Instructions/Comments: <br />j d <br /> <br /> <br />Kit Prep/Shipping Charge: $ <br /> <br /> <br /> <br />lient Sample Identification 1 Location Public Water System (PWS) [DO: /j/- V V vv y w <br />Project Name: Quote ID: ? LGN: <br />M-11'77-360 6 <br />Accotmi A Cash <br />. . Invoice to Name & Address: <br />x Standard Expedited (<10den Norw0wi flonraywred) Sc1v? e 115 <br />(aW.a rfra,.a.loborow <br />ad'DYl charges ^Wy apply) <br />Requested Due Date for Results: <br /> <br />P.O. or Contract No: <br />Requested AnalysialMethod <br />m <br /> <br />c? V <br /> <br />4 I ?` ` ( <br />Date Time <br />Sampled Sampled <br />o 6 , 1? l <br />z 9' !11 <br />. <br />100010,A(0 <br />Credit Card <br />r <br />Ui?Lt?" <br /> <br /> <br /> <br /> <br /> <br /> <br />o <br /> <br /> <br /> <br />a <br /> <br />m <br /> <br /> <br /> <br /> <br /> <br /> <br />m <br /> <br /> <br /> <br /> <br />o <br /> <br /> <br />g <br /> <br />ro rn <br />w <br />C 3D?- Vls Q q [I} /Z"G' dJ VV ? X /` .. x .. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />li ulshqAV: Dat Time Received by: Date Time <br /> q!4-110 /030 17 <br />Conditi <br />f THO ANC JNU FB S <br />Relinquished b . Date Time Received by Date Time on o <br />Custody Seal?; <br /> Initialed By: <br />Relinquished b : Date Time Received b : Date Time Temp/Loc: <br /> Thermo ID#, _ <br />Name of Sampler. (printed) <br />Version 20 Shipped Via: