2013-05-01_REPORT - M2010007

• Permit No: M2010007
• IBM Index Class Name: REPORT
• Doc Date: 5/1/2013
• Doc Name: ANNUAL FEE/REPORT
• From: OPERATOR
• To: DRMS
• Email Name: TC1
• Media Type: D
• Archive: No

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Laboratories, Inc.�� r�
2773 DOWW' p DfW Steamboat Sginnas, CO 80487 (800) 334 -
Name: Address:
mpany: r rni
E -mad: ADI . C Telephone:
Name: E -mail:
Tel one:
Name: Address:
Company: is
E -mail: Telephone:
If sample(s) received past holding time (HT). or if insufficient HT remains to complete YES
analysis before expiration, shall ACZ proceed with requested short HT analyses? NO
'NJ' IhM ACZ WIN COfKKt ClWn fix er fann KRdrix ion If nl Uw 'YES' nor NO
Kraled ACZ Will proceed vnt'l tie te*mw arlafyees. even If HT K —red and dM veil be qualified
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Are samples for SDWA Compliance Monitoring? Yes No
If yes, please include state forms. Results will be reported to PQL for Colorado
sampler's Name: Sampler's site Information State
Zip code Time Zone
QUOle i� N
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ro)ectlPO #.
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Reporting state for compliance testing:
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Check box 9 samples include NRC licensed material?
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Maft SW (Surface Wafer) • GW (Ground Wafer) ' W W (Waste Water) • DW (Drinking Wafer) - SL (Sludge) • SO (Sal) . OL (Oil) - Other (SPOCIFY)
Please refer to ACZ's temts 81 conditions located on the reverse side of this COC.
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FRMAD0S0.02.11.11 White - Retum wan sample. Tenow - reedianl Iw YWv1 -WI IHa.
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