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004 CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES AGREEMENT ** <br />CLIENT INFORMATION Evergreen Analytical Laboratory <br />Mail Original Report to: Quality Data on Tunee <br />i <br />Attn 4038 Youngfieid St. '(1 wiz ^ Wheat Ridge Colorado 80033 <br />Page_?of_ <br />(Date)* <br />ks ? <br />Address /^\ (303) 425-6021 Standariw;?L <br />City State _ Zip FAX (303) 425.8854 U Schedule ? <br /># Fax # (877) 737-4521 *Rush: O less than 24 hrs, 150% ? 1 -2 workdays, 100% <br />Tel <br />E-mail e-mail info@evergreenanalyfical.com <br />REPORT ALSO BY O FAX O PDF 0 EDD FAXED CONFIRMATION OF SAMPLE RECEIPT REQUIRED? (3 YES ? 3 - 5 rod days, 50% ? B - g wore days, 2596 <br />000^0'r e%J0^\AA'T/1/±CA**Q n --- <br />Invoice to: ??t 14t 1 +I <br />Mail <br />Attn MATRIX ANALYSES (check a aylsis) For Laboratory <br />Use Onl <br /> <br />Address <br />City State Zip <br />Tel # Fax # <br />Project ID# <br />P.O, Quote <br /> <br />Sampler <br />NOTE: ldenti6, Known Hazards oelow <br /> <br />SAMPLE DATE <br />IDENTIFICATION SAMPLED TIME <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />e <br /> <br /> <br />3 <br />$ <br /> <br /> <br /> <br /> <br />S <br /> <br /> <br />n <br /> <br /> <br /> <br /> <br /> <br /> <br />' y . <br />* W.O # <br />( B.O.F. # L 9 <br />CIS( <br />Y, ! crs I 0 NI) <br />`) <br />Tertp °G 2.1 / kte_. <br />~ r^ L <br />Seals PreeentY NA <br />V! RWON / NA. <br />. `= MeadepaceY/,N& <br />MW _0 !G 1p oc s <br />O <br />1')'1. iU _ P ., 121 X <br />.011W - 110 4- <br />u in, <br /> <br /> <br /> <br /> <br /> <br /> <br />Does this analysis Involve property transfer? ?Yes or ? No Sample Fraction <br /> <br />Instructions: j y ("A c?S <br />r ?Gl <br />k ff <br />•I <br />4-98 & 'Sut?JectlOSUrdtarge & exceptions noted in fee schedule. <br />52 _ t f, <br />....F.-.'twat. v00 WOVO14M aIw nawvi [VF LWIT 3 WKI UUMUnions. <br />Relinquished by: (Signatu , <br />d I'BC' !f?.' `_ Dete/Time <br />` <br />t <br />I63 Received y: (Signatu Da I'm <br />Ll ?1 <br />Y3a Relinquished by: (Signature) Date/rime Received by: (Signature) Detaffime