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-T- <br />Lab Name Green Analytical Laboratories (970) 247- 4220 LAX (970) 247 -4227 <br />Ai ,ilyscs Required <br />l b <br />/0 I o <br />, , cp <br />Comments <br />Addicss: 75 Suttic Street, Durngo, CO 81303 w\+;\1.,,rccnanai tica1 coII1 <br />� ! <br />1 <br />Sample ID <br />Coll:ction <br />Miscellaneous <br />PtL rvatIve(s1 <br />Datc <br />Time <br />‘,4 ppaHo, <br />• <br />:1011111011 <br />1, xplui <br />• To 'ON <br />1 <br />pJIIj <br />o <br />_J <br />()N11 <br />tOST:11 <br />HO \'N <br />■IpNls).131001 <br />1 . W11 2_Ca <br />3 -2 7 - 4- R2aP <br />a& <br />7 <br />a <br />, <br />2 <br />7- <br />N <br />•/ <br />Ni( <br />K <br />2.up <br />Do�x n,a,b.�. - <br />2H <br />{ =w5P <br />tL <br />i <br />3'2. .1 -R <br />3:00 Ip <br />ut <br />2- <br />z, <br />NI <br />_ <br />3-11-12. <br />rto 9 <br />s <br />1 <br />2 <br />A <br />> <br />.1m <br />'1:r <br />6. <br />� <br />R <br />9. <br />10 <br />Relinquished hy• <br />Date <br />1t S <br />Received by <br />D: to <br />Ti <br />Relinquished by. <br />Date: <br />Time. <br />Received by. 1 I <br />Date' <br />Tune <br />GREEN <br />Analytical <br />La boratories <br />Client G eiA <br />Contact. <br />Address <br />7 16t'r <br />‘z-173 C <br />it spei`u 5, Co At 3Za. <br />7o• 385 '452.0 lc <br />Phone Number <br />FAX Number. "/ (c v35 <br />* Sample Reject: [ ] Return [ ] Dispose [ 1 Stott (30 Days) <br />CHAIN OF STODY RECORD <br />NOTES <br />I) Ensure proper container packaging. <br />/�� <br />samples following collection <br />3) :hip <br />esignate Sample Reject Disposuton <br />10✓ - te r <br />Piolect Nana_ K;`, <br />Table 1. - Matrix Type <br />1 - Surface Water, 2 = Ground Water <br />3 = Soil /Sediment, 4 = Rinsate. 5 = 0t1 <br />6 -- Waste, 7 = Other (Specify) <br />Page <br />FUR GAL USE ONLY <br />CiAL JOB = <br />12-03- r2...:7 <br />Sampler, Signature C�mvw <br />Page 11 of 11 <br />