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r� a� rMANIE ENVIRONMENTArr WAIN-OF-CUSTODY RECORD LAB PROJEC <br /> > I c A Fj S (See Reverse for Instructions) NO <br /> PROJECT NAME SAMPLERS? T�t'� ��/j SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> ' {PRINT) � � DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER 7 4l •lL A 40 ml VOA Vial _ _ B surface Water G waste sta�daro <br /> t (SIGN) B Glass Liter I- grass lube C Leachate H BlanWSpike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rlnseate I Other3 24 Hour <br /> (SIGN) D Plastic Liter E SoAl rn-i nb 4 Other <br /> NUMBER OF ANALYSIS REOUESTED <br /> CONTAINERS LABORATORY USE ONLY a <br /> AND F ' <br /> g— a— PRESERVATION <br /> d s Y) g y Y SAMPLE 9 <br /> = LL— NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID — BOTTLE UPON <br /> vv' .� 1 S NUMBERS RECEIPT NOTES <br /> r .j ,� <br /> � I6 - <br /> rs 1 a F <br /> -------------- <br /> NOTES/MISCELLANEOUS l <br /> Remqulshed by (Signature R cel e - <br /> iI�{- a Y da ure) T / Date Te <br /> r �' r� rpt � ,' <br /> /g-o3Y Re 6quis ed By (Signature) » Ce Vo� y�( ,t re Date Time/ <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> �5�?' <br /> Method of Shipment Description of Other Chains-0f-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Con mer Transported with this <br /> Chain fir (by Serial No) <br /> Tl�djb <br /> Send Lab Results to (Name) -�(1at _/f W (Check Office Below) Verbals Requested Yes a-No-0 <br /> ❑ PORTER R1 PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHEfl <br /> TEL(219)926-8651 TEL(415)463-9117 TEL(714)7571755 TEL(404)951-0055 TEL <br /> FAX(219)926-7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)951-9364 FAX_ <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW .� <br /> TEL(303) 790-1747 ❑ OTHER <br /> TEL(215)337-2551 TEL(713)556-1666 TEL(415)960-1840 TEL <br /> FAX(303) 799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415)960-0739 FAX <br /> CANONIE ENVIRONMENTAL. SERVICES CORP o 800 CANONIE DRIVE o PORTER, IN 46304 a TELEPHONE (219) 926-8651 a FAX -219) 926-7169 <br /> SERIAL NO I WHITE Field Copy YELLOW PrDled Copy PINK Laboratory Copy <br />