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-C ANOME-ENY BONMENTAL MAIN-OF-CUSTODY RECORD PROJECT <br /> s (See Reverse for Instructions) NO ' <br /> PROJECT NAME —Q,+T tt'���._ SAMPLERS t �,1,,-Vt , SAMPLE CONTAINED SAMPLE DESCRIPTION CODES TAT CODES <br /> -� ` <br /> (PR iN DESCRIPTION CODES A Ground Water F Oil t <br /> PROJECT NUMBER—___1_C)Qq C�0 ! _ A 40-mt VOA Vial 8 Surlace Water G Waste 1 Standard <br /> (SAN B Glass Liter E Brass Tube C Leachate H BlankJSpike 2 4a Hour <br /> RECORDER --l«�� -- �� �- C Piasti.500-ml F Other D Rinseate 1 Other 3 24 Hour <br /> {SIGN) D Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> § AND 6e g <br /> 8m F <br /> e„ PRESERVATIO14AP <br /> _ <br /> I---- <br /> rs a � SAMPLE <br /> m € E~I < NOTES ASSIGNED CONDfTION <br /> DATE TIME SAMPLE !D N LL o' to ~— 2 E Z BOTTLE UPON <br /> t w NUMBERS RECEIPT NOTES <br /> tt u 1 <br /> — I A { t <br /> NOTES I MISCELLANEOUS ReliTipished by (Signature) Rgceiv By (Signature) Date ��� Time <br /> t QYy��...��� c�� �,.L; ellqulshed�By (Signature) R we By (S nat Date r `TIe <br /> JAI% y <br /> Relln ui d y igna ure) F1ceived By (Signature)` Date Time <br /> d T'9 f (, 0 L{S <br /> Method of Shipment Description of Other Chains Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial NO) <br /> � t _ <br /> Send Lab Results to (Name) It (Check Office Below) Verbals Requested Yes ❑ Nor, <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ Mf VIEW ❑ PORTER OTHER \�' A-s I , <br /> TEL(404) 951-0055 ti TEL (303)790-1747 TEL(714)7571755 TEL(415) 960-1640 TEL(219)926-8651 TEL 2r_lj. c, l !711 <br /> FAX (404) 956-9364 FAX(303)799-0186 FAX(714) 757-0960 FAX(415) 960-0739 FAX (219) 926-7169 FAX 7c;:3 ?c t c 1 K' <br /> ❑ BOZEM6N ❑ HOUSTON ❑ KING OF PRUSSIA ❑ Pi EASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406)586 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 (5101463-2981 FAX (503) 241-0486 FAX <br /> CA_N_ONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 3_0_0_ • ENGLEWOOD, CO 80111 • TELEPHONE 1303) 290-8336 • FAX (303) 290 8013_ <br /> SERIAL NO J n 7 1 .� WHITE Fluid Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br /> "fl 4 i <br />