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A <br />W <br />J <br />Ar. Laboratories, Inc.�9 -69 <br />2773 DoWVW Dave Stesiv beat CO 80487 (800) 334-5493 <br />Nery Address: <br />e: <br />E -matt: T - <br />Name: E-mail: <br />Teteplhone: <br />Name: Address: <br />Company: r <br />Z S <br />E-ma: T <br />z S <br />if sample(s) received past holding time (HT), or if insufficient HT remains to complete <br />YES <br />analysis before expiration. shall ACZ proceed with requested short HT analyses? <br />NO <br />'m0" Thin ACZ wm CCf" t heart rm i~ mmucoon r neew 'YES' na -mo' <br />is w*9Cale0. ACZ 00 ploCeeO with IMTeWssW snelysm even if Hi is w9hVG wd dada wW be quMdmil <br />Are samples for SDWA Compliance Monitoring? Yes No <br />ED <br />If yes, please include state forms. Results will be reported to POL for Colorado. <br />mpter's Name: Sampler's site Inrormation State <br />I Zip code <br />Time Zone <br />ill <br />t <br />ReporMV stale for compliance Cesdn9- <br />0 <br />Check bout If aamples WoMb NRC licensed <br />malarial? <br />o <br />T 1 <br />c coc�o�► <br />r­k" sW (&oftw vt Mw) - GW (Ground waterl • vvw Masre Wewr) • DW (off WOw) • st. (s xiw) • so (sue • OL (nit) • other ( Y) <br />Please Hafer to ACZs terms A oatditiorts totaled on the reverse side of ttds COC. <br />!eb <br />FRMAD050.02.11.11 White - Return with sample. Yellow - Retain for your records. <br />Page 9 of 9 <br />