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Company Name /Address <br />Alternate Billing <br />Time <br />t <br />Time <br />Analysis <br />/Container <br />Condition - - - use only F ".F _�—y- -_ <br />x <br />/Preservative <br />TenV:__ D <br />Receivilj'. <br />A062 Chain of Custody <br />Page t—of—t <br />Relinquisher by (Signature - <br />Date. <br />Time- <br />Reoenrpd for lab by: ( nature) <br />Date: <br />Time: <br />Molen & Associates, LLC <br />Prepared by: <br />2090 East 104th Ave Suite 205 <br />C3 <br />Thorton, CO 80223 <br />ENVIRONMENTAL <br />a <br />Science Corp <br />p <br />= <br />N <br />a) <br />li <br />12065 Lebanon Road <br />Report to Mark Molen <br />E -mail to molenassociates @gmaii com <br />g <br />,n <br />O <br />Z <br />w <br />to <br />a) <br />li <br />,V <br />Mt. Juliet TN 37122 <br />Project Description: Broda At Inert Fill <br />p <br />= <br />° <br />a t <br />v <br />2 <br />Phone (615)758 -5858 <br />Lab Project# <br />PHONE. 303.450.1600 <br />Client Project No. 10 -0133 <br />w <br />Phone (800) 767 -5859 <br />FAX 303.452.4515 <br />J <br />a <br />a <br />FAX (615)758 -5859 <br />Q <br />Y <br />J <br />C) <br />Z <br />Z <br />Collected <br />k A- �1 <br />lWFacilKy ID# Broda AI <br />P O # <br />-= poCode (lab use only) <br />+ <br />Q <br />m <br />� <br />U) <br />N <br />< <br />Q <br />oE <br />v <br />MOLENTCO <br />Collected by(sture : <br />(Lab MUST be Notified) <br />Date Results Needed <br />No <br />Same Day. ...200% <br />� <br />U <br />U <br />n <br />C) <br />Template/Prelogin <br />Next Day.. 100% <br />I.f <br />Y <br />m <br />Z <br />N <br />Q <br />Email? No Yes <br />Packed on Ice N Y <br />Two Day. .......50% <br />FAX? _No_Yes <br />cfl <br />Z <br />2 <br />U <br />O <br />C/) <br />J1-- <br />N <br />t>3i over Service Center <br />Sample ID <br />Camp /Grab <br />Matrix <br />Depth <br />Date <br />Time <br />C.ntrs <br />Remarks/contaminant <br />Sample # (lab only) <br />MW -1 <br />Grab <br />gw <br />lG 17 <br />�: <br />8 <br />X <br />X <br />X <br />X <br />__ <br />X <br />�S <br />-off <br />MW-2 <br />Grab <br />gw <br />l7 <br />(2 E <br />8 <br />X <br />X <br />X <br />X <br />X <br />X <br />_ o� <br />MW-3 <br />Grab <br />gw <br />(1(7 <br />O <br />1 8 <br />X <br />X <br />X <br />X <br />X <br />X <br />q3 , <br />k <br />- <br />pH Temp <br />qY2 A A JYtFIow Other <br />Relinquisher b (Signat <br />Date: <br />Ioi )1 <br />Date. <br />Time <br />t <br />Time <br />Received by (Signature) <br />Received by (Sign ture) <br />Samples returned via Fed'!; UPS_Other_ <br />Condition - - - use only F ".F _�—y- -_ <br />x <br />Relinquisher by (Signature <br />TenV:__ D <br />Receivilj'. <br />Relinquisher by (Signature - <br />Date. <br />Time- <br />Reoenrpd for lab by: ( nature) <br />Date: <br />Time: <br />pH Checked. NCF: <br />