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e?V Analytica Chain of Custody Form Page 1 <br />VII, 12169 Pennsylvania St 43D7 ArcBO 8culevard 475 Hall SL 5438 Shaune Drive <br />(((///??QJl/// Thornton, CC 80241 Anchorege,'AK 99503 Faik4nkis AK 99701 Jyheau, AK 99801 <br />AbIAI.YTICA co (303) 469.8868 (907) 258-2155 (907) 456- 3116 (907).780.8888 Chain of Custody No: 74 106 <br />taoup m (303) 4695254• fax (907) 258-8634 fax (9071456-3125 Fax (907) 780.6670 tax <br />Cliei David Bird I Public Water System (PWS) I'#: <br />C010. Div. of Reclam. Mining &. Safety II Project Name: Quote ID: 7LGIG 1313 Sherman Street, Rm 215 lq ?-- l 47 7- 3 6 0 <br />Denver, CO 80203 <br />Ciedit Card <br />Report to: S'?[l to 2 105M..M, :Invoice to-Name & Address: +j <br />Phone No: 30 2Ye-3.? e7 -K Standard Expedited j<10days. PKW3W nmIMQw*a} SC2i?[L G?f 1? <br />Fax No: 3?'-$3Z- 8 /L' 6T I .rw"?? Y ( dne.w. '' ?y <br />E-mail: CLv d . o,s`EW CO , 4--s Requested Due Data for Results- <br />Sp . e6ial Instructions/Comments: <br />[P.O. or Contras No: <br />JJ ?a. }?03 Ore- onto- o f loo [t? Reg4te$ted Analysis/Method <br />7 Fit Prop/Shipping Charge; $ <br />H <br />Date Time <br />m v° -° w <br />CITen! Sample Identification !Location Sampled Sampled <br />g ? ro ' ? m <br />o a U. <br />Z U. <br />C P? C7/4/1 tD c, ( ci- X X X _ <br />s .. w <br />r. <br />li quish 'Date Time Received by. Date Time <br />902+/16 /Q 30 Tlo ?4NC JN FBKS ' <br />Q 1 I _17o to: Condition of f <br />Relinquished by-, Date Time Received b Date Time Custody Seal?: <br />Initialed BY, <br />G Q _ ? <br />Relinquished by: Date Time Received-by, Date Time Temp1.€_oc: 5a ( o? <br />Thermo )D##; ' <br />Name of Sampler, (printed) S $ped Via: <br />Version 10