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i► QUALITY ANALYTICAL LABORATORIES CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES <br /> CH2M HILL Project# Purchase Order# -,. .,—LAw,TEST CODES SHADED AREA--FOR LAB USE ONLY <br /> r Lob t# , Lab 2# <br /> Protect Name <br /> # Quota# Kit Request# <br /> Company Name1CH2M HILL Office 0 <br /> C(_ F ANALYSES REQUESTED Project # <br /> Project Manager&Phone# Report Copy to: <br /> 0 I <br /> j Mr. j;r}_ C <br /> I Dr. [ 111] Q'A f�rS7A <br /> �p� O No:of Samples Page of <br /> Dr.Requested Completion Date: mpling Requirements Sample Disposal: T <br /> NPDES RCRA OTHER Dispose Return A I� <br /> f COC Rev Login LllAS Ver Ack Gen <br /> Type Matrix E <br /> I' Sampling O R A O CLIENT SAMPLE ID S )" <br /> (9 CHARACTERS) <br /> M A T I (�; I LAB 1 LAB 2 <br /> V REMARKS ID - ID <br /> Date i Time P I B R I L <br /> J <br /> E ^.a - <br /> t � i <br /> Sam a ,By& tl (plea a ion and print namel Da erT a Rellnqu' he By (Pleases ggn/�d print name) �,/ D tell a Uc� HAZWRAPINESSA: Y N�' <br /> Rec ived y <br /> (Please sign and print name} aterfime RelEn Uishe By (please sign and print name) DatefTime OC Level•,'l 2't3 Other:-.-�---- <br /> l COC Ree. ICE <br /> Received try (Plea**sign and print name) Dale/Time Relinquished By (Please sign and print name) DatelTime Ana Req �, TEMP . <br /> Cust Seat,� Ph <br /> Re ei ed By (PI a t ndprintname) DaterUme Shipped Via Shipping# r ��� <br /> /(w UPS BU Fed-Ex Hand Other-- <br /> Remarks L <br /> .� ork ulharized By (please sign and print name) Remarks _ <br /> I� 1 <br /> Instructionsgreement Provisions on Reverse Side , DISTRIBUTION:ORIGINAL-LAE,Yellotn\ �,k-Client <br /> Rr`v ,z-rORM 340 <br />