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CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES AGREEMENT <br />, Pagel <br />of <br />• <br />rINFORMATION - <br /> <br />G t Evergreen Analytical Laboratory Inc. <br />mail o <br />Mail original R ort to:r 66 <br />Alin .SyJ 4h ? <br />^ <br />4036 Youngfield St. <br />Report Results <br />by: <br />Date)' <br />( <br /> Wheat Ridge, Colorado 80033 Standard 2 working weeks <br />Address ^ (303) 425-6021 <br />' ` FAX (303) 425-6854 UST Analyses per Fee Schedule O <br />City State -Zip * ° <br />Tel # Fax # - <br />77)737-4521 <br />E-mail W 11 V5 ?R(?Oc? •?' i}B f <br />l <br />ti <br />l <br />Rush: (3 less than 24 his, 1500/• <br />[3 1 - 2 work days, 100 <br />/6 <br /> reenana <br />y <br />ca <br />.com <br />o ? 3 - 5 work days, 503'0 ? 6 - 9 work days, 25 /o <br />REPORT ALSO BY ? FAX ? PDF ? EDD CONFIRMATION OF SAMPLE RECEIPT REQUIRED? ? YES 'Subject to surcharge a exceptions noted in fee schedule. <br />nr-rvn i %.nnvmrAi %Jummnna u rvv <br />Mail Invoice to: J t Gill <br /> <br />MATRIX <br /> <br />ANALYSES (check nalysis) For Laboratory <br />' f, <br />GOB' h Use Only <br />y" <br />Attn <br />Address o H W.O. # <br />F <br />B <br />O <br />` `O m n <br />m <br />City State Zip <br /> <br />Tel # Fax # <br /> <br />v <br /> <br />N . <br />. <br />. <br />, \ <br />?? <br />& co <br />y +?C <br />C/S (0)0_W-'% <br />:i W N <br /> <br /> <br />Project ID# <br /> <br />--3 e <br />d o <br />& Q0 ?^ <br />C m C y Lu <br />s Np <br />, o m =`t 191 I <br />m m CIS(Q a m o w <br />° <br />P.O. Quote <br /> <br /> <br />Sampler v, ii <br />m o <br /> <br />m C9 <br /> <br />Q 0 <br />3 14 CY <br />a '? K <br />z O <br />. ? <br />ll ??( Temp. °CL / Ice____ <br />H °' <br />t o ^ a 3r Seals Ptt sentY /®/ NA <br />a m <br />E <br /> <br />Known Hazards Be%w <br />NOTE: Identif <br />' _ a H C0 <br />co 0 $ h H E 0 5 Samples Pro & N/ NA <br />y g <br />o o $ $ IN It <br /> <br />o <br /> <br />'1 <br />} 08 Y! N <br />SAMPLE DATE <br />° `- <br />' <br />0 a <br />4 m <br />a w a a R <br />° • <br />a ._` ? ?• ey?i"-? <br />IDENTIFICATION SAMPLED TIME z ;3 0 1 O _1 o = m ti + <br />? Q? $ Q <br />M (A) -o0q- tt 1 1 <br />VV'W -"00 2 1030 (14- 1 Ot <br />nww a O'D 1 <br />A- ' Q <br />0% <br />O 1 ?? <br /> <br /> h <br />Q G /??l <br /> <br /> <br />Sample Fraction 6G DIE F g <br />instructions: VleAM y.- S LAO(A ( •?J ?{j 0 0-2- ull <br />4 <br />•• Important Note: see reverse sine Tor terms ana conainons. Anions: rsromme, t,nionae, rvtiraie, roanie, v-rno5pnate, Suirtie tuircie) <br />Relinquished by: (Signs ) <br />04-0? DteJT <br />Q 0 Received by: lure) Date/r' a <br />??lt ?1 Relinquished by: (Signature) Date/rime Received by: (Signature) Data 'me <br />