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CANONIE ENV RO MEN LNAIN-OF-CUSTODY RECORD WO OJECT <br /> ay ('r I �55, (See Reverse for Instructions) NO <br /> PROJECT NAME SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRt�?y DESCRIPTION CODES A Ground water F OilPROJECT NUMBER �rr � A 40-ml VOA Vial B Surface water G waste i Standard) <br /> r �� _ (SIGN) B Glass Liter brass rube C Leachate H BlanklSptke 2 48 HSui <br /> RECORDER > "► u C Plastic 500 ml F b1her D Rinseate I Other_ 3 24 Hour <br /> (SIGN) D Plastic Liter E SoArSedlment 1 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> � AND 1i <br /> 5 PRESERVATIONY n <br /> ( r <br /> LL � SAMPLE <br /> qa NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> n D S <br /> S' b 4 r J <br /> RUQ et—IUri <br /> x <br /> TYE <br /> I l � <br /> r <br /> 1 l _ �I it <br /> NOTES/MISCELLANEOUS { <br /> X t)� rnCA. /�' Relinquished by (SignatU� ReceiByr (Signature) Date Time <br /> 7, <br /> Rr yrs, i <br /> ink.rig elinquished By {Signature) Received By (Sigrfature) Date Time <br /> ,fin! Wit{ 1�l �aH, DI, <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 /> ri <br /> Send Lab Results to (Name) '� f t (Check Office Below) Verbals Requested Yes 0/No ❑ <br /> ❑ PORTER PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <br /> TEL(219)926-8651 TEL (415)463 9117 TEL(714) 757-1755 TEL(404) 951-0055 TEL <br /> FAX(219)926-7169 FAX (415)463-2981 FAX (714) 757-0960 FAX (404)9519364 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW ❑ OTHER <br /> TEL(303) 790.1747 TEL(215) 337 2551 TEL(713)556-1666 TEL(415)960-1640 TEL <br /> FAX (303) 799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415)960-0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP C 800 CANONIE DRIVE o PORTER, IN 46304 0 TELEPHONE 219) 926-8651 • FAX (219) 926-7169 <br /> SERIAL NO <br /> 1 p in WHITE Feld Copy YELLOW Protect Copy PINK Laboratory Copy <br />