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The feaCrert Group Chain of Custody Record <br /> An Environmental Services Company Analytical Services Request <br /> 325 Interlocken Parkway,Suite 205-Broomfield, Colorado 80021 (enclose with each shipping container) <br /> (303)438-0970•FAX (303)438-0971 <br /> Client: i i 1Jl,L Y 4/ Contact: Z_ �l��/ hFr'/ !) ( Address: % e 1' /2 E Project Number <br /> 391 <br /> Program/She: :L�.tZ�� lL/,L�,l Phone: .' S`�" 3 5% , i �" 3Q/y <br /> r These fields may be used <br /> Collected by: for field test results <br /> c <br /> .0 z�Sample Date Sample <br /> Identification Sampled Time Type Q U Total <br /> ^C-1�ASl <br /> 1 <br /> 1 <br /> Condition on Receipt/Temp: , <br /> Comments: r�' 1/ <br /> Relinquished by: / Representing: a To Whom: 11'✓ DateTme: <br /> Relinquished by: Representing: To Whom: Date/Time: <br /> Relinquished by: Representing: Rec. at Lab By - - _ Dateff-ime: 9l2 y�vy OT04 <br /> WHITE COPY:Accompanies Samples CANARY COPY:Lab PINK COP Sampler <br />