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drNOftEMR NIM�TA��I-!'AO ION-OEM USTOD�RECORD `MVAB PR�I <br /> rne. Q, — Sr +-P ��mss, (See Reverse for Instructions) NO <br /> PROJECT NAME - �[�� f SAMPLERS-C;-490[ . SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT) DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBERJ ,_� „ A 40-mi VOA vial B surface water G waste 1i$laridard <br /> (Sd ) B Glass Liter E--HrCas Tube C Leachate H BlanklSpike 2 48 Hour <br /> RECORDER C Plastic 540 ml F Other orlseat@ I Other�_ e <br /> (SIGN) 0 Plastic Liter S41VSediment] _�_ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> U <br /> AND <br /> `a'eSIg PRESERVATION <br /> all SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID � f LL Z BOTTLE UPON <br /> NUMBERS RECEIPT NOTES i <br /> KA. /97 <br /> S P 2q AP 7A <br /> 701 <br /> _ 7' <br /> ) <br /> F1VTrG 81 <br /> f� <br /> NOT'TrES MISCELLANEOUS 1 Relinquished by (Signature) Resew By Slg atur ) bate Time <br /> L) n i l r J a9 � Z�7if 1 �.z I 1 C <br /> ([`��� J 3 / Rehnqulshed By (Signature)� Re lv '��I � /, �� � <br /> f 9 ) y ( g a ui 1 Dae Time <br /> �l� r" L,��-S !J✓l s/Ir 16. 1-rl LA DCVI C.,14 i <br /> `! �" " Q�'1OI�I r ce C1( - Sic r�-p Relinquished By (Signature) Received By (Signature) Date Time <br /> ' 1 •J t 4Z' <br /> Method of 8 ipment Description of her Chains-Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Tansport Container Transported with this i <br /> —'�- Chain(by Serial No) / -7 c� }) <br /> -- T -qf{ ) 1 y� <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes e-M ❑ <br /> ❑ PORTER C"PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <br /> TEL(219)926-8651 TEL(415)4639117 TEL(714)757-1755 TEL (404) 9510055 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 ❑ OTHER <br /> TEL(303) 790-1747 TEL (215) 337-2551 TEL(713)556.1666 TEL(415)950-1640 TEL <br /> FAX(303) 799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415) 960-0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP a 800 CANONIE DRIVE a PORTER, IN 46304 a TELEPHONE 219) 926-8651 is FAX 219) 926-7169 <br /> SERIAL NO WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy <br /> 1 ^ � �r <br />