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'14 CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> _ (See Reverse for Instructions) NO. <br /> PROJECT NAME 't SAMPLERSl!A ) - <br /> ' + SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 1 INTIn` r DESCRIPTION CODES A. Ground Water F. 00PROJECT NUMBER 'L-SIL _ A. 40 mL I VOA Vial B. Surface Water G. Waste Standard <br /> (SIGN) 8. Glass Liter E. Brass Tube G Leachale H. BlahldSpike 2, 4e Hour <br /> RECORDER u C. Plastic 500-m1 F.Other -I60110 D. Rinseate I. Other_ 3. 24 Hour <br /> (SIGN) D. Plaslic Liter /.: E. SdIUSedimenl 4. Other <br /> NUMBER OF ANALYSIS REQUESTED AAP��� LABORATORY USE ONLY <br /> CONTAINERS y <br /> oo ANO V <br /> '--am PRESERVATION 2 Q '7F 11A a o m <br /> y IEP <br /> 3 " o ?t a eE. z^ SAMPLE <br /> - -g : '-_° .j_ <m y`$ "Vo NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID H kit v-` a s mtrz <br /> z NUMBERS RECEIPT NOTES <br /> t <br /> - ll <br /> CJ <br /> v t ` <br /> NOTES MISCELLAN linquished hy: (Si lure) Received By: (SignWDateP11 <br /> Relinquished By: (Signature) R eived 8y: (Sign <br /> L,1 ONE �iwp� �� ar�4/yae DiVf- Relinquished By: (Signature) Received By: (Signature) Date Time <br /> A )PSS U S <br /> ethod o Sip ant ascription of Other Chains- f-C slody Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by SerialNo.) <br /> ' f,Iri I ( iii <br /> Send Lab Results to (Name): (Check Office Below) V rbals Requested: Yes Ow No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTEROTHER --p�q4 <br /> TEL(404) 951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL (415) 960-1640 TEL(219) 926-8651 -- - ,,A5 6a 2/ <br /> FAX (404) 956-9364 FAX (303) 799-0186 FAX (714) 757-0960 FAX(415) 960-0739 FAX (219)926-7169 FAX - ,21 <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND El 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 WHITE:Plaid Copy YELLOW:Project Copy PINK:Labora..y Copy REV 8192 <br />