DEQ-CFW_00022347

SAMPLE COLLECTION AND CHAIN OF CUSTODY RECORD
CLIENT
3$je $ij 1 1
4: n
C
ADDRESS
--
CITY
STATE ZIP
t �P f
PROJECT DESCRIPTION I NO, T OLIO NrION NO,
DNR FID #
CNR L ICENSE #
CONTACT
P3 TONE
PURCHASE ORDER No,
!"_AX
Wisconsin DNR ccrt I0
721026460 (Gran)1266633760 (Wank)
Wisconsin 13ATCP ID
105-000330 ( ran) t 105-000479 (Wank)
'"ATRI e
S1i' = _ttYf.._L tl ifU`f''
("'N i,Eik: n;3w.tigE
wFIF:
AIR = air
SED c iiri nt
= prod tat
511 it3f'tt4"
OTHER
NORTHERN LAKE SERVICE, INC.
Analytical Laboratory and Environmental Services
400 North Lake Avenue m Crandon, W1 54520-1295
Tel: [phone] . Fax, [phone]
NO.1922 2
ITEM
N1PL ID
a
MATRIX `� f Ust / J C CL LEF; i6 J REMt1RK5 I
t t I
NO,DATE
4
3
Th1E ;(SeAau);
;i,e.JNRVfa1113}
,,,
-----.
—
.........
.....
27
qg �
"'}4�E
1Li
i<1»yast,fi,
4,
3"%t
�T
�� •4iT
I i
{ a"
_
_
...------
�+
� 14. gg cq F
fA
y
.:..: _.
x.. .
8
6, •
-
rio
....-- ------- _ _ ....... -
I
-
------ ----- -
COLLECTED BY
SEAL. NO. (IF ANY)
RECEIVED BY (signatum)
€ ArEt'T'IME
DISPATCHED BYQslbpatw'd) METHOD OF TRAN"�P x� DATE1TIME
NTs- O fit' 4PTltntil@
Rev, 7l2W-As .
INVOICE TO
n nim, tciti OH x fitimfty'Jn d'z � WDNR FACILITY NUMBER � E MAILADDRESS
'' :nw i-t.eumz` li i 333G^t!ufi 3f1 ,� doUS33'IFf�' 11CIfl '
isS-rrxil,de:�l €-I t3,.tiYa.,Fti..,.c.tcu� ......... ..:
i. TO Est - T A,EGLIUN OI�?Y REQUiREPY�+I NTS. THIS FORM MUST PE COM?LETED IN €3EMIL AND Lh'S. L€. MED iN THE Ci:Cii.Er� (,0N- T;R INfNG `I'H SAF3,:PLES DESCRIED.
...
2. PLEASE USE ONE i. NE PER SAMPLE, NOT PER BOT T 11.
3, RETURN THIS FORM WITH SAMPLES -' ii,IENT MAY ' KECP YEL LOW COPY,
4, PARTIES COLLECTING SAMPLE, LISTED AS REPORT TO AND LISTED AS INVOICE TO AGREE TO STANDARD TERMS & CONDITIONS ON REVERSE,
DEQ-CFW 00022347