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CHAIN OF CUSTODY 1341 Cannon Street - Louisville, CO 80027 <br />rslaCrestGrou? <br />M.... N M .... C E 5 (303) 661.9324 -FAX (303) 661.9325 <br />?I.. <br />Client/Project Name: Co,• ?'c_ 4'ki a, ,. Analysis (Check all applicable) <br />P.O./Project Number: 5 -5-f'1 3 3 °; <br /> <br />Contact: J?c niG? (,9/ G 1; <br />o O <br />m O <br /> <br />m lJ <br /> <br /> <br /> <br />ddress: 13173-0 C: r V 'V f ?, 1, -e1q. l i %75`o <br /> <br />O <br />- <br />m <br /> <br />a <br />ca <br />v (2) <br /> <br />•' <br /> <br />+? <br />_ <br />4l <br /> <br />U 0 <br /> <br />y <br />W <br /> <br />3 <br />-° <br /> <br />N <br /> <br />Phone # % 7l`I -275-- 7y13 0=ZIG' <br />E-Mail: :j <br />° m <br />_0 C C <br />-, <br />3 <br />3 ` V <br />CU co <br />" <br />z 0 <br /> <br /> <br />Fax # /- 7/ `/ 2 7 S - / • cl <br /> <br />Sampler: -•? <br /> <br />Y v oc o <br />a <br />m <br />V <br />o o <br />N <br />°° <br />n <br /> <br />= <br />dl <br />o <br />W <br />to <br />o <br />F <br />'^ c <br />O <br />y <br />E <br /> <br />Report By: E] Mail F-1 PDF ? FAX <br />=3 <br />a O <br />-C <br />u a, <br />U <br />a <br /> <br />0- 'n <br />= <br />v ' <br />= E <br />:3 ? <br />E <br />o fa <br />a` O <br />a = <br /> <br /> <br />Sample Location or ID <br /> <br />Date <br /> <br />Time <br />Grab/ <br /> <br />Com <br />Lab ID <br /> <br />due W. O n, <br />F° <br />W <br />3 <br /> <br />W <br />3 <br />F <br />w <br />3 <br />~ <br />:'? <br /> <br />?, <br />o <br /> <br />a <br />o <br />-C <br />v C <br /> <br />- <br />o o <br />»- <br />o <br />u <br />o <br />o <br />co <br />s <br />•? <br />o <br />E <br />= <br />z <br /> <br />o <br />?- <br /> 7 10 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Turnaround Requirements <br />r, - <br /> <br />(Analytical ica TestiniOnlyl P 1? ® ? ? ? ) <br /> <br />Test Species: Y? Fathead Minnow Ceriodaphnia Daphnia magna DaPhniaPulex Other List Below) <br />Standard (10 days) 6-9 Day <br /> <br />3-5 Day 1-2 Day <br />Requested Report Date: <br />Special Instructions/Comments: c.iG? c `i r`1 e ^ 7 c: 1, / - , S 2 S S 5" / <br />Relinqushed;6y {i): - .` . Received'By_j1j;- ` Relinquished By (2) Received,By (2) <br />Sign tur Date/Time <br /> <br />-g-/ <br />z Si wr <br /> <br />i- Date/Time <br /> <br />2°+ do Signature Date/Time Signature Date/Time