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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD - LAB PROJECT <br /> 11'' d (See Reverse for Instructions) t ��� yL NO. �,. ,� i <br /> PROJECT"E U `1+- an �D 9 A A SAMPLER"(SIGIN) <br /> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A. Ground Water F. at <br /> PROJECT NUMBER r1" n 1 A. 4 rnl VOA Vul e. Surface water G. Waste t Standard <br /> B. Glass Leer E Brass Tuve C Leachale H BlanuSpike 2. 48 Hour <br /> C Pitman,5 rnl F Other _ _ D. Rmseale I Other 3. 24 Hour <br /> (SIGN)RECORDER D. Phum.Leer E. Soil/Sed,mem _ _ 4. Other <br /> _ - -_ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY _ <br /> CONTAINERS C <br /> D 4 <br /> 3— 5— PRESENRMRION s— F¢3 p Eyy gY_ <br /> NOTES SAMPLE <br /> ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID a NUMBERS RECEIPT NOTES <br /> y• - # Yz <br /> ar T1. <br /> /� A4 <br /> NOTES I MISCELLANEOUS '1 t1)t a r CIA linquished b : (Sign ure) ei By: ( 'g tura D <br /> CR . t Time <br /> `c <br /> �tte. • �od1 rin7t i rtIJ NINC. U ` - <br /> 19 . 9 s2`Io n IJ t I k00 Gia elinquiahed By:(Signature) eceived 8y: na re ate Time <br /> �od'I <br /> '"� <br /> Ljo� K r, Relinquished By: (Signature) Received By: (Signature) Date Time <br /> S <br /> Method of Shipment Description of Other Chains-01-Custody Dispatched By: (Signature) Date Time Receiv for la y: ( ur ) ate Time <br /> Transport Container Transported with this <br /> Ct n Chain(by ial No) <br /> Send Lab Results to (Name): (Check Office Below) erbals equested:/Yes ❑ No ❑ <br /> ❑ PORTER ❑ SAN MATEO ❑ IRVINE ❑ ORLANDO ❑ OTHER <br /> TEL(219)92&8851 TEL(415)5738012 TEL(714)757-1755 TEL(407) 856-7428 TEL--- <br /> FAX <br /> EL _FAX(219)9267189 FAX(415)5735654 FAX(714)757-0960 FAX (407)8552595 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT. VIEW ❑ OTHER __ _ <br /> TEL(303)7901747 TEL(215)337-2551 TEL(713)5561866 TEL (415)960-1640 TEL _._ <br /> FAX(303)799-0186 FAX(215)337-OSM FAX(713) 556-OGW FAX(415)960-0739 FAX <br /> CANONIE ENVIRONMENTAL LABORATORY a 212 FRANK WEST CIRCLE, SUITE A e STOCKTON CA 95206 0 TEL.(209) 983-1340 a FAX 983-0304 <br /> SERIAL NO 0338 7 WHITE:Flald Copy YELLOW Protect Copy PINKLaiaoratory Copy <br />