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silverstate 3638 E. Sunset Rd.,Ste. 100, Las Vegas NV 89120 CHAIN-OF-CUSTODY RECORD <br /> Phone: (702)873-4478 Fax: (702) 873-7967 <br /> j Analytical Laboratories p 4587 Longley Lane, No.2, Reno, NV 89502 <br /> www.ssalabs.com Phone: (775)825-1127 Fax: (775)825-1167 Page of <br /> ProlectfJob#., Payment Method/PO#: Q Name: <br /> p <br /> Name: / <br /> C G Company: ��/•..+ 1 G>/�i �/� /jvL� <br /> Company' ¢w Mailing <br /> EOD <br /> Mailing Address: 9-6 7"" u� O tQ- City,State Zip; ✓C� �J �� <br /> City,Slate,ZIP: J W <br /> v ¢" Phane: O� (07/� Fax Emal1:. ,{ O��° <br /> 61 L <br /> Sampled By: Turnaround Time(Specify Below with an X): Olher Pertinent Info: _ <br /> G6k x�a © ANALYSES REQUESTED Circle Applicable Program: <br /> Standard�o Business Days <br /> Report SDWA OWA RCM Other Non-Reg <br /> Alierilon: <br /> 7 Day 1 2 Day 3 Day Other —\ Reporting requirements: <br /> On-Site pHlremlwrnture: <br /> ���jjj U RL MDL POL <br /> NOTE: A surcharge Is applied for rush samples <br /> z \ Report Level: <br /> Dale Time Sample Locator✓ Silver State Comp/ Matrix• Preservative 1 II [if IV <br /> Sampled Sampled Sample 10 Lab ID Grab NOTE:sw.yr appry bLMlle.nd Nage, <br /> /o: �-� CTS -,✓� �'`> � NA �/-� <br /> 'Metals: <br /> NT vE - X <br /> .X X <br /> 7/b - lU vE 7A/Z <br /> Tamperhlg Wth sample name,date,time,and location may consdtute fraud /�•�� <br /> Relinquished t, Received by <br /> SI nature/Print: TimalOate: ' s S nalure/p n• G/ �_ Tlmo/Date• ���/� <br /> Relinquished by Received by <br /> SI nalure/Print: 7lrrrelOate: 5nature/Print: Time/Date: <br /> Method of Delivery: Receiving Laboratory: <br /> spe,al Insuucons:J <br /> Authorized �1�I�Q/G <br /> rAuDate:lhorizalion Is u requYed la prooaa samples.Thla ooligelns your orgenizailon for foo pertaining to services randerad.If cdlecGans or legtl amvkm are <br /> required to recover meld lees,your organizrlbn w41 be responalde Wait laos and Dost In addition to service lase• - Nole:Sam lss sn dkcerded 30 day,slier restos am re oriod.Gemp4es domed hazardous are reNmed to are lent upon�m ledcn of snel Is. <br /> Key:AQ—Aqueous S—Soil W—Waste OT—Other —Key:P—Plastic G—Glass V—VOA Vial OT-Other <br />