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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD 4% LAB PROJECT <br /> Y (Se Re erse for Instructions) NO.--q 0. 6 - <br /> PROJECT NAME 7nOf D t_ �i / SAMPLER / RINT) SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER A. 4Dml VOA Vial B. Surface Water G. Waste 1. Standard <br /> (SIGN) ` - Glass Liter E. Brass Tube C. Leachate H. Blank/Spike 2. 48 Hour <br /> RECORDER C. Plastic 500-mI F.Other D. Rinseaie I. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF CA YSI. REQUESTED LABORATORY USE ONLY <br /> CONTAINERS ti, - <br /> 'm o AND <br /> —5 PRESERVATION >°y �m o E q a <br /> q% Iff2 ESAMPLE <br /> Sm °z ri a <br /> EP NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID Em - m - ' 'Ll E BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> �z 9 !B: a <br /> ------- ---------- <br /> ------- ---------- <br /> ------- ---------- <br /> ------- ---------- <br /> ----------------- <br /> hr <br /> 3 h' <br /> M <br /> NOTESISCPELLANEOUS'�;\ ,t e Iia�i. R inquished by: ignature) eiv y: (Signal e),; /c Cate Time _ <br /> 5 Relinquished By: (Signature) Received By: (Signature) Date Time J <br /> � A �-� G' Relin uished B Si nature Received 8 (Signature) Date Time <br /> ld or•� q Y ( 9 ) Y ( 9 ) <br /> �T7i <br /> Method of Shipment Description of Other - - t Dis a d By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> n Transport ntainer Transported with this <br /> UPJ'/ Chain (by Serial No.) <br /> Send Lab Results to (Name): f T (Check Office Below) Verbals Requested: Yes ❑ No ❑ <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) 855-2595 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT. VIEW ❑ OTHER <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) 983-1340 - FAX (209) 983-0304 <br /> SERIAL NO. 01328 WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy <br />