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Company Name: <br />G ' ��/ f . foci ' <br />Project Name, PWS, Permit, Etc. <br />t/" l ( ��-10 t4 t I D 1 �e <br />Sample Origin <br />State: CO <br />EPA/State Compliance: <br />Yes • No j <br />Report Mali Address: <br />Contact Name: Phone/Fax: Email: <br />Sampler: (Pl <br />• • <br />Invoice Contact & Phone f <br />ANN ( �+4 /IL6( <br />Purchase Order: <br />Quote /Bottle Order: <br />, 2-$ 1 1 -fi-5 - <br />, <br />• - • • • <br />■ ' <br />. a <br />Number of Containers <br />Sample Type: A W S V B O DW <br />Air Water SoilsISolids <br />Vegetation Bioassay Other <br />DW - Drinking Water <br />A N A LVVD& MC <br />IK M <br />Standard Turnaround (TAT) <br />[ <br />Contact ELI prior to <br />RUSH sample submittal <br />for charges and <br />scheduling — See <br />Instruction Page <br />S ' by` A <br />—rut -) <br />Go o i er I ts • 3 <br />Cm) J <br />3722 <br />11-72 320n J <br />$*2 Z g )2n 1 <br />SEE ATTACHED <br />Receipt 'temp <br />Comments: <br />- MIS-7 <br />iii <br />On Ice: g N <br />■ ■ , <br />Custody Seal 0 <br />On Bottle Y <br />On Cooler Y <br />Intact Y N <br />Signature Y N <br />. • <br />•, : <br />- <br />MATRIX <br />1 <br />letogArreki PoerA t.. <br />5 ti <br />K20 <br />tu <br />K <br />1 D E TOT <br />fe014 nx <br />.„S a <br />2 Pfz Sea -i/�ri <br />i51Pr1 t <br />1630 <br />w <br />X <br />o <br />3 w— i <br />4211 <br />I L I 00 <br />w <br />x <br />x <br />■ <br />eg 8 <br />g <br />7 <br />8 <br />4 <br />LO <br />9 <br />- <br />DO <br />� <br />10 <br />Cus ` ody <br />Y <br />R @CO rd <br />MUST be <br />Signed <br />Relinquished b (pr int }: D j em �/� i - <br />.A# �� r,�. � 14-4'7 it rV oe <br />. , -� <br />Received by (print): Darerr Signature: <br />Relinquished by (print) D aterr ime: . at <br />Received by (print): Da Signature: <br />Hecelved b Laboratory: DateJTime: ��. ' <br />S ample Dis • osal: Return to Client: _ Lab Qis al: _ _ /C7 (j <br />ENERGY <br />=IN — ■ ■ —' M' MIR NM ■ ■, NW I I a <br />Page 1 of <br />Chain of Custody and Analytical Request Record <br />PLEASE PRINT (Provide as much information as possible. <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis t.rgtluested. <br />This serves as notice of this possibility. All sub - contract data will be clearly notated on your analytical report. <br />•r+rn fnr additional information. downloadable fee schedule, forms, and links. <br />