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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO. <br /> 40JEC-r-NAME1r 0464- SAMPLERSAL•� %I� <br /> _ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT)-:� r DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER 17,?, C)I'O�- 1r `�`K�-" -i A. 40-ml VOA Vial B. SurlaceWater G. Waste 1. Standard <br /> (SIGN) B. Glass Liter E. Brass;Tube ��gfrhd[e - H. Blank/Spike 2. 4a Hour <br /> C. Plastic 500-m1 .Other'-_1.�w Ei� Rinseale - I. Other 3, 24 Hour <br /> RECORDER D. Plastic Liter C1I (-- D<< E. SoglSedirnent 4. Other <br /> ' (SIGN) <br /> L <br /> NUMBER of I ANALYSIS RECWES ED LABORATORY USE ONLY <br /> GONTAINERS <br /> 1���1fa^J 1! • _^m <br /> PRESERVATION r. I� J +'1 � S b_ 4 <br /> c r ;o ¢ x J!. s= E: ¢ N�_ c SAMPLE <br /> '-. �, -A a z v <br /> 1� a �5 NOTES ASSIGNED CONDITION <br /> �' _ a O—' 4 <br /> ;DATE --UPE ;. , g 'SAMPLE Ip ' ; � .0 at y Z .BOTTLE UPON <br /> NUMBERS RECEIPT N46 <br /> 'Y`w <br /> QW <br /> 97 1201` yti! >' <br /> 0 � tootis , r v Q3u '(;.5 <br /> T. <br /> i <br /> f - <br /> NOTES 1 MISCELLANEOUS ` Relinquis (Signaturceived S S' nature Date Time <br /> �. } ,t ( (: 7 ) Cl�i� f�J�r <br /> F 1 Relinquished By (Signature) Reeenad By, ignature) Date ¢_me. <br /> ramS <br /> ex*A 5 Relin wished B Si nature `Received B ~ <br /> G Y ( g. ) �; t Y: (Signature) Date TIm9 <br /> m , <br /> ;Method of Mpmertt IL, Description of Other Chains-Of-Custody Dispatched, By: (Signature) Date Time Received for lab By::(Signature) D to Time ` <br /> 06 L7. t - Transport Container Transported with this <br /> t <br /> x i Chain (by Serial No.) ' <br /> Cir <br /> � r <br /> ;sencf'Lab R6'suIts to Name —) ��4}t1�fJE C?YY15 <br /> ( ) (Check Office Below) .:Verbals Requested: Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ 'DENVER ❑ IRVINE ❑ MT. VIEW ❑ .PORTER ❑ OTHER <br /> TEL(404) 951-0055 TEL(303) 790-1747 TEL (714),757-1755 - TEL (415) 960-1640 ..TEL(219) 926-8651 TEL <br /> FAX (404)956-9364 FAX(303)799.0186. FAX (714) 757-0960 FAX(415) 960-0739 FAX (219) 926.7169 FAX <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> L(406) 586-9496 TEL(713) 556-1666 TEL(215)337-2551 TEL(510) 463-9117 �TEL,(503)241-0282 TEL <br /> (406)586-9724 " 'FAX(713) 556-0666 FAX(215)337-0560 FAX (510) 463-2981 FAX(503)241-0486, FAX <br /> #AYIONIE E,VIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290 8013 <br /> SERIAL NO. 1'`-A CZ .4 C .. WHITE:Feld Copy YELLOW:Project Copy PINK:Laboratory Copy REV.W92 <br />