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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> 17 �1 ,� (See Reverse for Instructions) NO. 3 <br /> Z -3 <br /> PROJECT NAME no r L% vt ( SAMPLE R�f1 N __ [A. <br /> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> c�• 5—Q 5 a ( Tl DESCRIPTION CODES A. GlouM Water F. oil <br /> PROJECT NUMBER 4Dm1 VOA Vial B. snnaca Water G. wsu 1. Stanmrd <br /> (SIGN) Glass Liter E. Braes T.W C. Leachate H. BMnMSpiMe 2. aBHour <br /> RECORDER PlastK 5 ml F.other_ D. Rmseate 1. 0IRNr_ B. 24 Hour <br /> (SIGN) Plastic Uter E. SaVSediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND yy g <br /> S—g PRESERVATION 11 <br /> E€ H # SAMPLE <br /> I €F 11 NOTES ASSIGNED CONDITION <br /> s ' BOTTLE UPON <br /> DATE TIME SAMPLE ID ` I g NUMBERS RECEIPT NOTES <br /> 4.31- c + I EE ' yq <br /> OL <br /> NOTES MISCELLANEOUS ( pa{I,I Rep ,ed by: (Signature) eiv y: (Si net ) Dats rime <br /> �2f fljLe_ 1 /, I�.NA / <br /> c. �. <br /> A Fplihquished By: (Signature) Received By: (Signature) Date, � Time <br /> aZU MR 1�5 Reli 1 quish By: (Signature) Received By: (Signature) Date Time <br /> I h F` • t S Fµ:,J 1 <br /> C <br /> Metpod o�t Description of Other Chains-Of-Custody Dispatched By: (Signature) Date Time R for lab By:(Signature) Date Time <br /> Tran R lainat Transported with this <br /> Chain (by Serial NoJ <br /> Send Lab Results to (Name): OC o 6 (Check Office Below) Verbals Requested: Yes ❑ No Cl <br /> ❑ PORTER ❑ SAN MATEO ❑ IRVINE ❑ ORLANDO ❑ OTHER <br /> TEL(219)926.8651 TEL(415)573-8012 TEL(714) 757-1755 TEL(407)856-7428 TEL <br /> FAX(219)926-7169 FAX(415)573-5654 FAX(714)757-0960 FAX(407)856-2595 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT. VIEW ❑ OTHER t <br /> TEL(303) 790-1747 TEL(215)337-2551 TEL(713)556-1666 ` TEL(415)960.1640 TEL <br /> FAX(303)799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415)960.0739 FAX <br /> CANONIE ENVIRONMENTAL LABORATORY -,212 FRANK WEST CIRCLE, SUITE A - STOCKTON, CA 95206 - TEL.(209) 98&1340 - FAX (209) 983-0304 <br /> SERIAL NO. 01326 WHITE:FIeM Copy YELLOW:I'Mon Copy PINK:L ralory Copy <br />