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Lab Name: Grecn Analytical Laboratories (970) 247 -4220 FAX (970) 247 -4227 <br />Analyses Required <br />z 0 0 cC #J <br />VlO t (,&- <br />Comments <br />Address: 75 Suttle Street, Durango, CO 81303 www.greenanalytical.com <br />Sample ID <br />Collection <br />Miscellaneous <br />Preservative(s) <br />Date <br />Time <br />Collected by: (Init.) <br />Matrix Type <br />From Table 1 <br />No. of Containers <br />Sample Filtered ? Y/N <br />Unpreserved (Ice Only) <br />EONH <br />'TJH <br />OSZH <br />HOYN1 <br />Other (Specify) <br />1. W i Li1C Well <br />(9 - ll <br />;.•34>i <br />z• c, <br />Z <br />2 <br />N <br />A <br />2.4) tA 11/46 4 <br />6 <br />2 = <br />Tc <br />2 <br />2 <br />11 / 4 1 <br />K,i\A Z <br />3.x:2 ,_ - .. ' .1,' <br />66-11 L <br />2 %6D r.,, <br />T4 <br />2 <br />Z <br />5. <br />6. <br />7. <br />8. <br />9. <br />10. <br />Relinquished by:. - <br />Date:r <br />T' e: C– <br />Received b <br />` <br />Dat • <br />Ti e: <br />Relinquished by: <br />Date: <br />Time: <br />Received by: <br />Date: <br />Time: <br />OREM <br />Analytical <br />Laboratories <br />Client: to c - �kUG' <br />Contact: Te701 k- <br />Address: C,17 3 a ,z l z,.0 <br />* Sample Reject: [ ] Return [ ] Dispose [ ] Store (30 Days) <br />CHAIN OF CUSTODY RECORD <br />1) Ensure proper container packaging. <br />2) Ship samples promptly following collection. <br />3) Designate Sample Reject Disposition. <br />Cep . P t 3Lt, <br />Phone Number: 1Z( -)g5.. y 52.¢ X & a3 PO# <br />Email: 9 7 / 5 " 3 —. 144. 3 g Project Name: l \ 1 <br />it t cy) jca cowl P l�.�. � i 1 � 5 =PO tig- <br />Table 1. - Matrix Type <br />1 = Surface Water, 2 = Ground Water <br />3 = SoiUSediment, 4 = Rinsate, 5 = Oil <br />6 = Waste, 7 = Other (Specify) <br />Samplers Signature: <br />Pace) of <br />FOR GAL USE ONLY <br />GAL JOB # <br />fW(o-IL/ <br />Page 11 of 12 <br />