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Y12 CANONIE ENVIRONMENTAL HAIN-OF-CUSTODY' RECOR® 1_AH Pfla.IEcT <br /> r - (See Revert If <br /> Instructions) Nr1 ' <br /> t <br /> PROJECT NAME J'"1 �^G�n t^" i� SAMPLERS t lut"� SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES _ <br /> � ,N Ii FT) DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER ~U�DTV- �k �� A. 40-m1 VOA Veal B. surface water G. waste 1. Standard <br /> J (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. BlanklSpike 2. 48 Hour <br /> 5u/r IW <br /> RECORDER � C. Plastic Soo-m! F.Other D. Rinseale I. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. SoHlSadiment 4. Other ;..,.4.., <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERSu <br /> AND ` a °v _ <br /> g a^ PRESERVATION $ 4 S <br /> g� � I am =m SAMPLE <br /> �m I-, <br /> NOTES ASSIGNED CONDITIONDATE TIME SAMPLEIDy LL iT` �V NUMBERS RECEIPT NOTES <br /> _ A 4 <br /> _ I <br /> _Z t <br /> S -T~- <br /> SS -�- -z t — <br /> S ' <br />� S f <br /> NOTES!MISCELLANEOUS t j�te 9 Ishfd by: i�nature) gepelved By: $Ignatyre) Date Time <br /> 1'uA�f C.�ip +ruwt� 4cr��l��firitL 'r!`l� ; !: �J (' <br /> / / Relinquished By: (Signature) Received By: (Signature) Date Time <br /> .c CGfnr Sr f� �{ �PS Z. : 1 �S 1 rtCO �t -- a <br /> I� A� . Relinquished By: (Signature) Received By: (Signature) Date Time <br />\ Method of S ipment Description of Other Chains-Of-Custody Dispatched By: (Signature) Date Time Received for lab By: (Signature] Data <br /> Tlme <br /> Transport Container Transported with this <br /> Chain (by Serial No.) <br /> Send Lab Results to (Name): 1 t C (Check Office Below) Verbals Requested: Yes ElNo El <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER OTHER <br /> (4fl4) 951-DOSS TEL (303) 790-1747 TEL(714) 757-1755 TEL(415) 960-1640 TEL (219) 926-8651 TEL- <br /> TEL 2xf <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 /> TEL(406) 586-9496 TEL(713) 556-1666 TEL(215) 337-2551 TEL(510) 463-9117 TEL (503) 241-0282 TEL <br /> FAX(406) 596-9724 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 ,x303) 290-8336 • FAX (303) 290-8013 <br /> PINK'Laboratory Copy REV'8l9. <br /> SERIAL NO. ,� r� WHITE:Meld Copy YELLOW:Project Copy <br />