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004 . CHAIN OF CUSTODY RECORD / ANALYTICAL SERVICES AGREEMENT ** <br />CLIENT INFORMATION Evergreen Analytical Laboratory <br />?• Quality Data on 7ime® <br />Mail Original Report to: _? <br />Page <br />?? <br />Yv <br />"I U Y'` <br />Att <br />r • /N 4036 Youngfield St. <br />R? Report Results by: (Date)* <br />-0_ <br />? <br />n n_T_ Wheat Ridge, Colorado 80033 yard 2 waidng weekay <br />Address (303)425.6021 <br /> FAX (303) 425.6854 UST Anatyses per Fee Schedule ? <br />City State - Zip (877) 737.4521 <br />* Rush: ? less theft 24 hB,15096 <br />O 1- 2 work days, 100% <br />Tel # Fax # E-mail e-mail into @evergreenanalytical.com O 3 - 5 work days, 50% ? 6 - 9 work days, 25% <br />REPORT ALSO BY ? FAX ? PDF ? EDD FAXED CONFIRMATION OF SAMPLE RECEIPT REQUIRED? ? YES *Subject to surcharge & exceptions noted in fee schedule. <br />FIEPUFiT GMRUMA UUKAMb V xE ' <br />Mail Invoice to: C? <br />MATRIX f0f"L a OrBtOry <br />ANALYSES (Check a Isis) <br />r:?";Usfb°Only'. <br />Attn <br />Address <br />City State Zip <br />Tel # Fax # <br /> <br />Project ID# <br />P.O. Quote <br /> <br /> <br />y <br /> <br /> <br />o wi: d. ?.35 <br /> <br />B.OA 0 <br /> <br />aws ®r) <br />O ? <br />fempc °C /Ice ',? <br />Sampler <br /> <br />NOTE: ldentlfy Known Hazards Below <br /> <br />SAMPLE DATE <br />IDENTIFICATION SAMPLED TIME c <br /> <br /> <br />o <br /> <br />z <br /> <br />"' <br />S a <br /> <br /> <br />o <br /> <br />o O ?^ <br />p :::9eals PraesntY/ N / NA <br /> <br />Sar??pies !+?•/ N 1 PIA <br />P <br />Heads paoa.Y / N IXA , . <br />By <br />' <br /> 5;112J 0 q 10 zS t"L- qd 1 A )d )4 )4 A- 6j.. <br />no I'S 1 4' t v2 . <br />- o <br />(142 A <br />......_. <br />1L <br />G.. <br />.,. -01 <br />3 t <br />r35:'.; <br /> <br /> <br /> <br /> <br /> . . . <br />pose this analysis involve property transfer? OY es or O NO DE! { Sample Fraction <br />Instructions: I'( •g8k T-71 t -tr+'' oil Me- f--^ t S <br />** Imoortent Note: See reverse side hereof toNe ? Rle . <br />Relinquished by: (Signs Date/rime Received by: (Signature) Datelrime Relinquished by: (Signature) Datell ime Received by: (Signature) DateMme <br /> <br />Son- Ca, K W\1? -?0 e-" 0-®6s2