2012-06-28_PERMIT FILE - M2012032 ‎(20)‎

• Permit No: M2012032
• IBM Index Class Name: PERMIT FILE
• Doc Date: 6/28/2012
• Doc Name: Appendix 4 & 5
• Media Type: D
• Archive: No

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Laboratories, Inc
2773 Dovmttitt Drive Steamboat . CO 80167 (900) 334.54
Name: Levicki & Associates Address: 11541 Warrington Ct
E -mal: Tel no: (303)346--!5196
Name: John R. Trujillo
E -mail: 'rt@tru'illodevelo ent.co
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Name
Address:
Company:
Parker, CO 80138
E -mail:
Telephone:
if sample(s) received past holding time (HT)• or if insufficient HT remains to complete YES X
analysis before expiration. shall ACZ proceed with requested short HT analyses? NO
'Nf)' MIeA ACZ will unUd Ubnl lef Aatbw 1liWLIMlf1 M rk� 'YEti' ns Tp'
NM cord. ACZ wle peCeee YAUI ew fe¢IeMed AAeylsS CWA It Hl Is e■WAAI. AN Mu well be VwIM W
Are samples for SDWA Compliance Monitoring?
Yes No
if yes, please Include state forms. Results will be reported to PQL for Colorado.
mpler s Name: Sampler's site information
State
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Quote #: MINE - WATER
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Sw (surface water) ' Gw (Ground water)' WW (Waste Water) • DW (DdnMw water)' SL (Sludge) ' SO (Saq' OL (Oil) - other (SpsaYY)
2 coolers with 48 bottles
Please refer to ACES terms & conditions located on the reverse side of this COC.
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FRMA6060.02.11.11 While. Return With sample yellow - herein for your nwurva.
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