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cev SCIENCES LABORATORY alp <br /> Q <br /> CHAIN OF CUSTOuY RECORD AND AGRE11ATT6 P&%0JSERVICES <br /> CH2M Hill Project# a Purchase Order# <br /> J L EL 't Z a LJ L i iL Li.t�LZI <br /> Project Name <br /> # <br /> Company Name/CH2M HILL Office O <br /> C4tZV-t 4tLC 1 Sir 0 F <br /> Project Manager&P one# Report Copy to: ANALYSES REQUESTED <br /> Mr. wj �.SI�Le.�S C <br /> Dr.'[ <br /> Cs,n��zsi-z sig x2to, k.5hee_ks <br /> Requested Completion Date: Sampling Requirements Sample Disposal: T <br /> A <br /> SDWA NPDES RCRA OTHER DISp Return I ;i <br /> ❑ ❑ © ❑ N <br /> Type Matrix <br /> Sampling C G W S A S J <br /> O R A O l CLIENT SAMPLE ID <br /> P B E L R (9 CHARACTERS) <br /> Date 71me R L <br /> Sampled By&Tme' {Please sign mW print name � O AG <br /> p„ ) Datem a Resin ui ed B <br /> `' q i {PI neneprintneme] Dateme <br /> 'Received B Y tl 2.( t C�1. i l X15 l - <br /> n nt ) DateTme Relinquished By �+l nand print name) DatelTime <br /> Received By Yip, '° e"°pp'n'�410> z ` Re E wished B <br /> L� y (Pleaae sis,.ndprfM name) e!T e <br /> .Received sn am print nom) . Date/Time Shipped Via Shipping# <br /> O }z0'f j()rJ UPS BUS FedEx Hand Other <br /> Work Authorized By (Please sign and P rteme) Remarks <br /> Instructions and Agreement Provisions on Reverse Side <br /> DISTRlBLrI70N:Origins!- LAB,Yellow- LAB,pink•Glenn <br /> REV 3194 FORM 340 <br />