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,; �.` <br /> ENVIRONMENTAL -"HAIN-OF-CUSTODY RECORD ICAB PROSEC' <br /> ''(See Reverse for Instructions) L., <br /> PROJECT NAME ISAMPLERS r: <br /> NO. <br /> - 7J/' Ill f-- f.�_.F t; SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES '• <br /> {PRINTF DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER.._- r�lp "� :�1 (� �. . ,; r A. 40-ml VOA Vial <br /> T��••� - — _•�'r--=.-,—:—'� B. surface water G. wrists <br /> (SIGN)! B. Glass Liter' E. Brass Tube ad <br /> RECORDER C. Plastic 500-ml F.Other CC.. Leac Leachatate I. Other <br /> Leachate H. BIanWSpike 2. Stndar <br /> (SIGN[ D. Plastic Liter E. Hinse3. 24 Hour <br /> ediment <br /> - 4. Other <br /> NUMBER OF ANALYSIS REQUESTED <br /> CONTAINERS ry LABORATORY USE ONLY <br /> g <br /> AND m e m <br /> ;— oo PRESERVATION v -� $;, a A a <br /> °m �d .�g i=a� SAMPLE <br /> DATE TIME SAMPLE iD N— LL� t� .. f o— NOTES ASSIGNED CONDITION <br /> i'- I+, BOTTLE UPON <br /> z NUMBERS RECEIPT NOTES <br /> + ? , <br /> fT <br /> IV V <br /> NOTES I MISCELLANEOUS wRelin uished b Si.nature <br /> v f Y• ( 9 y: (Signature) Date <br /> L rn� i �� r; 1,`.1 f' , �� Q _.-... 1 Received B Time <br /> f� Relin uished B .. <br /> Q Y (Signature) <br /> Received y: (St afore ; <br /> Ig ) Date Time <br /> • t <br /> ReJ3n4 Find B (Signature) Received B (Signature) <br /> ' Y ( 9 ) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatchod By: (Signature) Date Time R coined for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No.) <br /> 114' 4 <br /> Send Lab Results to (Name): 4 4 I &L <br /> (Check Office Belo ) Verbals Requested: Yes ❑ No [] <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE , <br /> ❑ MT. VIEW ❑ PORTER <br /> TEL.(404)951-0055 TEL (303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(210) 926-8651 / O�HER f �'rl l <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX (714) 757-0960 FAX (415) 960-0739 FAX(21 926-7169 <br /> FAX _` 1T <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASAN 'ON ❑ PORTLAND <br /> TEL(406) 586-9496 TEL(713) 556.1666 TEL (215) 337-2551 TEL(510) 463-9117 TEL TL: 241-0282 ❑ OTHER_ <br /> FAX (406) 586-9724 FAX (713) 556-0666 FAX(215)337-0560 FAX (510) 463-2981 FAX (503) 241.0486 FAX <br /> TEL <br /> CANONIE ENVIRONMENTAL SERVICES, CORS • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE '303 290-8336 • <br /> SERIAL Np. /� - WHITE:Field Ca YELLOW;Project Co t ) FAX (3D3} 29Q-8013 <br /> _t <br /> 14 <br /> Copy 1 PY PINK:Laboratory Copy REV.g+92 <br />