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Lab Name: Green Analytical Laboratories (970) 247 -4220 FAX (970) 247 -4227 <br />Analyses Required <br />Comments <br />Address: 75. Suttle Street, Durango, CO 81303 <br />Sample ID <br />Collection l <br />Miscellaneous <br />Preservative(s) <br />Date. <br />Time <br />Collected by: (Init.) <br />Matrix Type <br />Prom Table <br />No. of Containers <br />po-raallJ olduteS <br />Unpreserved (Ice Only) <br />£ONT I <br />101-1 <br />I-12SO4 <br />HOVN <br />Other (Specify) <br />r <br />r <br />. �' <br />r <br />0. <br />i- <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />' <br />ion r' ;: <br />/ . - <br />r <br />Relinquished bsi % !;ri - / <br />Date:. -- <br />Time: <br />Received by: — r <br />Date' <br />Time: <br />Relinquished by:• - <br />Date: <br />Time: <br />Received by: <br />Date: <br />Time: <br />• <br />Analytical <br />Laboratories <br />/ ,•:"; ..I <br />Client: j'� — - - — <br />Contact: 7 l: ^ rT %f ; / packaging. <br />Address: ■° j G , ; collection. <br />c (:‘;' 3) Desig,nate Sample 'Reject Disposition. <br />Phone Number: <br />FAX Number: <br />* Sample: Reject: [ ] Return [ ] Dispose [ ] Store (30 Days) <br />CHAIN OF CUSTODY RECORD <br />PO# <br />Table 1. — Matrix Type <br />Surface Water, 2 - = Ground Water <br />3 = Soil /Sediment, 4 = Rinsate, 5 = Oil <br />6 = Waste, 7 = Other'(Spccify) ,! <br />Project Name: / !',. %rr y jj �,: •`?���1• f' i! Samplers Signature. 1 , r, - -,., <br />Page <br />• <br />FOR GAL USE ONLY <br />GAL JOB # <br />