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*PROJECT,41 <br /> CANONIE ENVIRONMENTALONAIN-OF-CUSTODY RECORD <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME _ n k-WWOtSAMPLERS_&7/11-141 Sr,o,W4 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PROJECT NUMBER "►� 333 0� 4 I INS DESCRIPTION CODES A Ground water F Oil <br /> A 46m1 VOA Vial a Surface Water G Waste 1 Standard <br /> (SIGN) 6 Glass Liter E Brass Tube C Leachate H BlankfSpike 2 48 Hour <br /> RECORDER C Plastic 5Mrnl F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soll/Sedimeni 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> �¢ AND 4 Y <br /> li— PRESERVATION it a_ <br /> J'® Y SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID BOTTLE UPON <br /> = NUMBERS RECEIPT NOTES <br /> K I vt <br /> a �s )"ITO q t3 A x 3 X 1 lr <br /> -A 3.0 iv, 3 4, a 4 3- V <br /> 1 MW <17 ) <br /> 0 a 55 19 n1 v-, S' , D A 1 3 7; y <br /> o�d�`1S 1 Ta- IZ M 3 � ti <br /> NOTES/MISCELLANEOUS ,Q Relinq fished by (Si nature) Recelved By (Signal u 9) Date Time <br /> Relinquished (Signature) Received By (Signature) Date me <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-0f-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) / o rT, (Check Office Below) Verbals Requested Yes ❑ No 0-- <br /> El <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW 0 PORTER OTHER <br /> TEL(404)951.0055 TEL(303)790.1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219)926.8651 TEL a -F� 9j <br /> FAX(404)9589364 FAX(303)799-0186 FAX(714)757-0960 FAX(415)960-0739 FAX(219)926-7169 FAX &Aj-_P_3r d q <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 586-9496 TEL(713)556-1666 TEL(215)337-2555 1 TEL(510)4639117 TEL(503)241-0282 TEL <br /> FAX(406)586.9724 FAX(713)556-0666 FAX(215)337-0560 FAX(510)4632981 FAX(503)241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP a 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 80111 a TELEPHONE 303 290-8336 a FAX 303 290-5013 <br /> SERIAL NO15 S 8 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 11112 <br />