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QUALITY ANALYTICAL LABORATORIES CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES <br /> CH2M HILL Proj/ec/t# Purchase Order# <br /> rt LAB TEST CODES ' `� `.., ':,_ .. - SHADEI];gREA-FOR:LAB-USE ONLY <br /> a?�� eL14� IL.E Labe La62S; <br /> w <br /> Project Name y �Ss So <br /> L AN # r ouotef# s; <br /> Klt Request�! <br /> Company NamalCH2M HILL Office <br /> p <br /> Project Manager_&Phone# Report Copy to: ANALYSES REQUESTED <br /> Mr. [�]��MS ` <br /> Dr. ri <br /> Q� f}U2T1�F O k <br /> N No of Samples Page of s <br /> Requested Completion Date: Sampling Requirements Sample Disposal: T L p , <br /> r SDWA NPDES RCRA OTHER Dispose Return A _ i <br /> r prL tc'Ics ❑ ❑ ❑ ❑ ❑ [ : <br /> N ,COG'Rev .,�''Login _ LIMS-Ver, .Ack,Gon <br /> Type Matrix E Q l <br /> Sampling <br /> C G W S CLIENT SAMPLE ID R Vi <br /> O R A O S <br /> P <br /> (9 CHARACTERS) � <br /> A T I <br /> Date Time P B E L REMARKS Ip ;ID.. <br /> JAJ <br /> - - <br /> r <br /> - - . <br /> E3, E 4 <br /> e. I - <br /> _ <br /> ki <br /> .._ r ., .._.. __._..._. ..._... .. -_,., .__ <br /> algnand print na na) Da By lona sign and rml name) DateM HAZWRAP/NESSA 'a Y <br /> L. <br /> PR7,,edlF )Plaaaa algn and print Mme) Datelllme linqul$hed By IPleean sign and prim name) De eM;ne QC Level: 1 8 00werst <br /> COC Rae V i ICE'. <br /> Received By (PNaaa sign and print Mme) DateMme Relinquished By IPleasa sign and print name) DateMme :Ar►s 1Req. a; IIE11IIP.,._" <br /> Cuat Seal -:Ph <br /> Received B IReaN signph Print�») D te/Tlme Shipped Via Shipping# Q C <br /> UPS BUS Hand Other 2-S—�V <br /> Work Authorized By sign so print n.ma) Remarks <br /> !-Instructions and Agreement Provisions on Reverse Side AISTRIB{171014:ORIGINAL-LAB,Yellow-LAB,Pink-Client <br /> REV 11192 FORM 34D <br />