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The leaCrert 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: J ' I r r.144 '_ Contact: f d!"✓ C!"/JJ& Address:-&/ G/a0/" te- 42Y' Q Project Number <br /> ' SVt'ki /� i c� qa 0 <br /> Program/Site: " I '� Phone:j�j '3 .�7",f��3 "tG J7 ;C <br /> !� These fields may be used <br /> Collected by: 2 ' ' 2 for field test results <br /> c <br /> m o o w a+ <br /> Sample Date Sample Q U �? <br /> Identification Sampled Time Type Total <br /> Condition on Receipt/Temp: ! <br /> Comments: p a <br /> 11 <br /> - _: / !_4 S DateTnJ To Whom: me: <br /> Relinquished by: ''z — Representing: -- _., <br /> Relinquished by: Representing: To Whom: Date/Time: / <br /> Relinquished by: Representing: Rec. at Lab Date/Time: 4`Lo ley <br /> WHITE COPY:Accompanies Samples CANARY COPY: Lab PINK CO : Sam ler <br />