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Client Name & Address: G 5 e� f y <br />j f c-! <br />C., /0 s�o r ti t.td C a .kt <br />X h - o ►1 . Sf . '2-j S <br />�i - Q N �vV1 . <br />Report to: 41:21Lii� I <br />Phone No: 303 -. O 66. � . j 6 7 7 X • �! b <br />Public Water <br />r Syst (PWS} ID#: <br />' • +' t* '' + �q <br />"i�"',' ,�;. �a'�i <br />' <br />Project Name: <br />dl lc" � r' <br />Turnaround <br />Standard <br />Quote ID: <br />LGN: „ 18 <br />Account #. <br />1 e rivet' , c V <br />P.O. or Contract No: <br />Cash <br />g 2_0 <br />Credit ezrci <br />3 <br />§..tin <br />.L <br />1 1 <br />Fax No: <br />E-mail:bit ch r a <br />Requested Due Dace r vr rceaulcs: <br />�1.�`' <br />T <br />Special Instructions/Comments:: Si' Q,. c& . u5 <br />1 - C e A r,C,,C.t fQ, Ni, Z et <br />:CC e(MS) /1'S Cd fb i1 1 Se, �� <br />" <br />Requested Analysis/Method <br />:gym <br />°off <br />• <br />p L:• 002 <br />Mgr <br />• -Y ;M <br />Field Preserved I <br />Field Filtered <br />MSIMSD ? <br />Kit Prep /Shipping Charge: S <br />Date <br />Sampled <br />Time <br />Sampled <br />Matrix <br />(8 -DW -WW Dthor) <br />No. of containers <br />Client Sample Identification / Location <br />F} lic,•A sd.u/ t <br />", t l <br />i/ t3o <br />✓ <br />✓ <br />. <br />At c 5Q M ' <br />a /. I l <br />r 0 <br />✓ <br />'/ <br />Relinquished by: <br />Date <br />Time <br />R i d by: <br />Dates <br />ime <br />Mi` <br />eigr I� <br />;,5 iOM; <br />i t ; <br />? ,a' i ;illi•B <br />i <br />y • i. <br />Watt <br />) 1,44 . <br />1O f c /tj <br />id: <br />(fit <br />/a. 3e. <br />/ <br />)0/ IQ /L) <br />Condition of <br />Custody Seal?: <br />Initialed By: <br />Temp/Loc: <br />ThermoID#: <br />Shipped Via: <br />THO ANC <br />_._, ..___._.____._ <br />-- <br />_... <br />JNU <br />,., <br />- .___._.._ <br />_..__._.__.._ <br />FBKS <br />__._,_.._. <br />_ - - -� <br />S • 6`(-- <br />__.....__..... _ <br />________ <br />____ <br />—_ - <br />-- - -_ <br />... ..-._.. <br />-- <br />Relinquished by: <br />Date <br />Time <br />R cei ed by: <br />Date <br />Time <br />Relinquished by <br />Date <br />Time <br />Received by <br />Date <br />Time <br />Name of Sampler: (printed) <br />ANALYTICA <br />caouae <br />Version 2.0 <br />12189 Pennsylvania St <br />Thornton, Co 80241 <br />(303)489.8868 <br />(303)469 -5254 fax <br />Analytica Chain of Custody Form <br />4307 Arctic Bouievartl <br />Anchorage, AK 99503 <br />(907) 258 - 2155 <br />(907) 2584034 fax <br />475 Hall St. <br />Fairbanks. AK 99701 <br />(907) 456 - 3116 <br />(907) 4563125 Fax <br />5438 Shaine Drive <br />Juneau. AK 99801 <br />(907) 7806668 <br />(907} 760.6670 fax <br />Chain of Custody No: <br />Page _—_ of__ <br />