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M NOVIM <br /> ' Mo" <br /> CANONIE ENVIRONMEN=rAL AIN-OF -CUST DYOWECMD RO <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME _�, SAMPLERS -1 , , L,4 !ii--, -,c ,- SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (�F1INT) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUN1Bf fT��_�T'1'� ter_ j _ ,�l J �,�. A 40 MI VOA Vial B Surlace Water G waste 1 Standard <br /> r, (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER1 _--� A ,. - 4 T C Plastic 500 ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Lrler f ,! .1"( E SoillSediment 4 Other <br /> .-....Y NUMBER OF /J4ALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS I M s e <br /> AND <br /> A^m om PRESERVATION $ m x <br /> if x <br /> LL: [` 8- ;€¢ ar =� SAMPLE <br /> DATE TIME SAMPLE ID <br /> m� oel m-<6 NOTES ASSIGNED CONDITION <br /> am am m z u i <br /> M Cr d E -11 <br /> BOTTLE UPON <br /> Y�L D _L ^� F`� 0z NUMBERS RECEIPT NOTES <br /> r- <br /> r r <br /> i l l 3 1 ) r 3» t <br /> k- <br /> 1 <br /> V 11r �_1) <br /> NOTIy51 MISCELLANEOUS Relinquished by (Signature) R cel ed B (Signature) Date Time <br /> - <br /> r ltnqul hed q (Signature) R ved try Ig ure Dat k( Time <br /> Relinqutshe By-(Signature)- Received By (Signature) Date Tie <br /> Method of Shipment Description of Other Chains Of-Custody Dlspatch,)d By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> r _ Chain (by Serial No) <br /> z <br /> 1"I")I <br /> Send Lala FIR-suits to (Name) k1'. - __ 0,. -- A \\, (Check Office Below) Verbals Requested Yes 11 No <br /> ElLlr <br /> ❑ <br /> LJ AFLANIA ❑ DENVER IRVINE ❑ MT VIEW PORTER C}�(7THER <br /> TEL (404) 951-4055 TEL(303) 790-1717 TEL(714)757 1755 TEL(415) 960-1640 TEL(219) 926-8651 TEL 7_r_ -)!I 7)>4 <br /> FAX (404) 956 9364 FAX (303) 799-0186 FAX(714)757-0960 FAX(415) 960-0739 FAX(219)926 7169 FAX 2e sl , :74.-7>2 Q <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 5S6 9496 TEL(713) 5561666 TEL (215) 337 2551 TEL (510) 463-9117 TEL(503)241-0282 TEL <br /> FAX (406) 586 9724 FAX (713) 556-0666 FAX (215) 337 0560 FAX (510) 463-2981 FAX(503)2410486 FAX <br /> CANONIF_ ENVfRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO WHITE Field Copy YELLOW Protect Copy PINK Laboratory copy REV SM2 <br /> A� <br />