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' t CANONIE ENVIRONMENTALICA' IN-OF-CUSTODY RECORD QAB PROJECT <br /> (See Reverse for Instructions) NO <br /> r <br /> PROJECT NAME Ir rrr`Tr.,.JIT1yei fi/SAMPLERS 1 �� 1 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINTI _ DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER !7q ?1 r r 1 O t (If it +/ r, [ A 40 ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) — B Glass Luer E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rinseete, I Other 3 24 Hour <br /> (SIGN) D Plasuc Liter E SoillSedimenE 4 Other <br /> NUMBER Of: ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION m <br /> x� o- <br /> 3� mS LL 4J lI So E E¢ o �� SAMPLE <br /> 0 9V Qm E m°q� NOTES ASSIGNED CONDITION <br /> E� am a LL� !t t't `V E °v BOTTLE UPON <br /> DATE TIME SAMPLE ID 1 �' (i+ z NUMBERS RECEIPT NOTES <br /> y ' l <br /> L a <br /> r I <br /> Y � <br /> J ' f <br /> j W , <br /> �J <br /> / / <br /> NOTES/MISCELI,ANEOUS Relinquished by (Signature) Received By (Signature) Date Time <br /> 11 SAS ir'bI t.1(I 1 ,r', "� r t` �� n( , <� <br /> i� Relinquished By (Signature) Received gy (Sig-dature) Date Time <br /> Rlnqui h� B (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of Custody Dispatched By (Signature) Date Time R celved for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) 7 <br /> 1 r Ilk <br /> Send Lab Results to (Name) ,r (Check Office Bela ) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE / ❑ MT VIEW ❑ PORTER ��OfHER "f {.-7�) <br /> TEL(404) 9510055 TEL(303)790-1747 TEL(714) 757-1755 TEL(415) 960 1640 TEL(216)926-8651 TEL -Y <br /> FAX(404) 956-9364 FAX (303) 799-0186 FAX (714) 757 0960 FAX (415)960-0739 FAX (21� 926-7169 FAX <br /> .li <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 /> t <br /> FAX(406) 586-9724 FAX (713) 556-0666 FAX(215) 337 0560 FAX (510)463-2981 FAX (503) 241-0486 FAX <br /> r <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 Field Copy YELLOW Project Copy PINK Laboratory Copy REV a192 <br /> r .14 i t <br /> -rL . 4 _ <br />