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a <br />moms <br />s: M <br />W <br />J <br />JACZ Laboratories, IncA qqD!N <br />zr13 Dot riftill DOW sreamboaf s CO av4a7 (aoo) �Name: <br />R-1 Rkk <br />(i �f A I S t L F-A Address: p 0 <br />Corrilw : 81jagg cou"Ty RI D $ I .1a, <br />E -mail: C- i r* 0 r C u Tele hone: q"70 <br />Name: Mejj JE -mail: <br />Co : t�j `{ t� r N G �-6-G Telephone: <br />@- a a 0 <br />(o -' O d.� <br />Name: Address: <br />Company: <br />E -mail: Telephone: <br />It sample(s) received past holding time (HT), or if insufficient HT remains to complete <br />analysis before expiration, shall ACZ proceed with requested short HT analyses? <br />'r10• Inen ACZ wul anted tllMt ra tanner Ihrrucllon. rnrthar'YES' nw •!10• <br />India", ACZ will P MO with UM requMfed MrJ,eee, a If Hr W exorwl, ene dae 111 M quraed <br />YES <br />NO <br />Are samples for SOWA Compliance Monitoring? Yes <br />K es, please include state forms. Results will be reported to Pt'2L for Colorado. <br />No <br />mpler s Name: Sampler's site Information State <br />Zip code Time Zone <br />Quote S. <br />_ <br />U <br />`o <br />0 <br />0 <br />M <br />Projed/P0 #: <br />Re state for compliance <br />Check box if samples Include NRC licensed material? <br />u o r <br />o <br />50 <br />Matrix SW (Surface water) GW (Ground Water) • WW (Waste Water) • DW (Drinlung Water) - SL (Sludge) SO (Sop) • OL (Oil) • Other (Spedfy) <br />Please refer to ACZ's terms & conditions located on the reverse side of this COG. <br />FF(eE =!O PM <br />77 <br />i <br />FRMAD050.02.11.11 White - Return with sample. Yellow - Retain for your records <br />Page 13 of 13 <br />