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( CANONIE ENVIRONMENTAL( "HAIN-OF-CUSTODY RECORD ( .AB,RROJECT <br /> -tom, (See Reverse ror Instructions) Nu. <br /> PROJECT NAME KLOUER ��1'QCf2-ry SAMPLERS .41-EX T(tIQFS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q IN DESCRIPTION CODES A. Ground Water F. oil <br /> PROJECT NUMBER l r�^ �2" 'A— A. 40-m1 VOA Vial B. 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 500-ml F.Other D. Rinseate 1. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND Y <br /> g— — PRESERVATION $ $' <br /> 121a - y <br /> ¢� x SAMPLE <br /> $� g� = $yo NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE I TIME SAMPLE ID _ v = NUMBERS RECEIPT NOTES <br /> IOWS W- I ✓ I I d ✓ <br /> o MW-2 A ✓ 3V ✓ <br /> /0231 o - A Al I ✓ 3 ✓ <br /> NOTES/MISCELLANEOUS -�1WTUL17WO (-wAWS SO Relinquished by: (Signature) R ceived By: Signat re) Date Time <br /> r QPb�or p t O <br /> AQC�catJ N1m a l,A Gr►s AND dr6 b r <br /> �T' k PP Relinquished By; (Signature) Received By: Ignature) Date Ti <br /> �VEAs� 'P(0411>6 GbPIEc 6 Relinquished By: (Signature) Received By: (Signature) Date Time <br /> LEASe lJoTs mP )EMPC9A v nN A (-%LOWI'I(i' 0GV-AM%. <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 /> ,4U-000- C40W r✓R, 'kA&)c 77 <br /> Send Lab Results to (Name): W I( lL I A M MAMISOO (Check Office Below) Verbals Requested: Yes No El <br /> 1:1 El DENVER El IRVINE El MT. VIEW El PORTER L✓J OTHER L'S <br /> TEL(404) 951-0055 TEL(303) 790-1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL 9 S- 07 <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 El OTHER <br /> TEL(406) 586.9496 TEL (713) 556-1666 TEL(215)337-2551 TEL(510)463-9117 TEL(503) 241-0282 TEL <br /> FAX (406) 586.9724 FAX (713) 556-0666 FAX (215)337-0560 FAX(510)463-2981 FAX(503) 241-0486 FAX <br /> l CANONIE ENVIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-80-13---1 <br /> SERIAL NO. 15553 WHITE.Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV.8192 <br />