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at <br /> CANONIE ENVIRONMENTAL SAIN-OF-CUSTODY RECORD PROJECT; <br /> A.1 ��� �� � �����erase for Instructions) NO <br /> PROJECT NAME SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> `�y - - <br /> 01 - O y DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER I S-{�- A 40-ml VOA Vial a surface water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 5OG-ml F Other D Rrnseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS a <br /> AND g <br /> PRESERVATION �Y <br /> LL �' l64 re a SAMPLE <br /> "O NOTES ASSIGNED CONDITION <br /> �~ BOTTLE UPON <br /> ATE TIME SAMPLEID § a =, NUMBERS RECEIPT NOTES <br /> .# -TIN I i <br /> A, ` <br /> 11� ! MW ) 14 <br /> I d S l n1 w s d <br /> Y <br /> NOTES 1 MISCELLANEOUS Reilnq Ish by (Slgc>alure) Reeved By ( �gnae) �1 Date Time <br /> Relinquished By (Signature) Received By (Signature) 'rime <br /> Relinquished By (Signature) Received By (Signature) Date Time <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} aa^"'"'t w o,,,— r► {Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER r` <br /> TEL(404) 951-0055 TEL(303)790-1747 TEL(714)757-1755 TEL(415) 960-1640 TEL(219) 926-8651 TEL 9 S ?r �5"� <br /> FAX (404)956-9364 FAX(303)799-0186 FAX(714) 757-0960 FAX(415) 960-0739 FAX(219) 926-7169 FAX 6`01 01 <br /> I <br /> Q aOZEMAN Cl 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)2410282 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) 290-80113 <br /> SERIAL NO r r WHITE Field Co YELLOW Proecf <br /> � I SPY PINK Laboratory Copy REV 8192 <br />