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TORRMI'IRONMO'A HRR- UTOE'15RI' #IPRffCT <br /> (See Reverse or Instructions) N0. <br /> PROJECT NAMEAC L_ UrjTrW SAMPLERS rex prr-S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PROJECT NUMBER . _21 -0 1 N� A 4Surface <br /> DESCRIPTION CODES A Water F Oil <br /> VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Liter E Brass u C Leachale H BlanklSpike 2 48 Hour <br /> RECORDER C Plash 505-ml F Olher D Rinseale I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoIVSedrmenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> OONTAINERS <br /> AND <br /> — PRESERVATION �, + <br /> o ` a SAMPLE <br /> V �€ f 3 NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> d) 84 225 w- F A A 1/1-7 <br /> IZSKA kil- v V <br /> NOTES/MISCELLANEOUS Relinquished by (Signature) TrIved By (Signatu e) Date Time <br /> know Ly,-Ab sAKIPtEzA C��, Relinquished By (Signature) Received y ( Ignalure) We Time <br /> J�`3 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} Dale Tlme <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> t�� COo - ►z- 45 a sA,4 <br /> --u U a <br /> Send Lab Results to (Name) 5 .` (Check Office Below) Verbals Requested Yes ❑ No El <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER e OTHER WES <br /> TEL(404)9510055 TEL(303)790.1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926 8651 TEL 5 1 <br /> FAX (404)956.9364 FAX(303)799-0186 FAX(714) 757-0960 FAX(415)960-0739 FAX (219) 926-7169 FAX20 91519-27ZS~ <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 586-9496 TEL(713)558.1666 TEL(215)337-2551 TEL(510)463-9117 TEL(503)2410282 TEL <br /> FAX(406) 586 9724 FAX(713)55"65Q FAX(216)337-0560 FAX(510)463 2981 FAX(503)2410486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 303 290-8336 • FAX 303 290-13013 <br /> SERIAL NO 1 [� 7 1 r, WHITE Field Copy YELLOW Prolecl Copy PINK Laboratory Copy REV 6192 <br />