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J/ CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> / (See Revere for Instructions) NO. <br /> PROJECT NAME CA' Of Sfrxk&4 -IQ I SAMPLERS tl . ICLW (: lkh SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Pyl DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER �t4 - A. 40.ml VOA Vial 9. Surface Water G. Waste t Standard <br /> c , I (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. Blank/Spike 2, 48 Hour <br /> RECORDER 1 C. Plastic 500 m1 F.Other ill D. Rinse Is I. Omer 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. SoiliZubmenl _ 4. Omer <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> `- PRESERVATIONLLS § n n' <br /> s 11 e : fck i€ 'a <br /> s _ 0 c a. ig SAMPLE <br /> a'$ a`—'oP NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID aS �Y� ( �- _ F i BOTTLE UPON <br /> ~ NUMBERS RECEIPT NOTES <br /> - a 1 <br /> Of <br /> _I ) <br /> "10 p t h <br /> -, <br /> ------- --------- <br /> ------- --------- - <br /> U <br /> a , <br /> NOTES J MISCELLANEOUS _6 TEL inquigf;ed by:d( nature) Received/ By: (Sign. tur ) Date Time <br /> y As rTe C�Cr rL, C-Y�(A <br /> tiICJ��4(rlNi;�r{-(']C'(�- ( J J I / I Relinquished By: (Signature) Re ived By: (Signature) Date Time <br /> Cu� F�/�) f(y , Al1) Se.� f(y / �"1/ �..f1 e- Wa&P-N <br /> F <br /> �-¢rte <br /> FPA Relinquished By: (Signature) Rived By: (Signature) Date Time ul(Fluxr )ntifihy (N aPrrJcarrlxlnsctY>.5/4 Received <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 /> Send Lab Results to (Name): t1A (Check Office Below) Verbals Requested: Yes ETINO ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER 2 OTHER AJAS& <br /> TEL (404) 951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415) 960-1640 TEL(219)926-8651 TELA -7r;^> <br /> FAX (404) 956-9364 FAX(303) 799-0186 FAX(714)757-0960 FAX(415) 960-0739 FAX (219) 926-7169 FAX � <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL (406)586-9496 TEL(713) 556-1666 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)241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. ,a ry j•- WHITE:Field Copy YELLOW:Protect Copy PINK:Laboramry Copy <br /> (1 REV W92 <br />