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= E ENVIRONMENTALt%AIN-OF-CUSTODY RECORD aPROJECT' <br /> " (See Reverse for Instructions) NO. <br /> PROJECT'NAME SAMPLERS .f�-'v�� 1t /amu �1 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> f Z (PRINT) DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER ��w• t r. A. 4aml VOA'vial B. Surface water G. Waste 1. Standard <br /> (SIGN) B. Glass Liter, 1=. Brass Tube C. Leachate H. BlanIdSpike 2. 48 Hour <br /> RECORDER •hy Cry C. Plastic 500-m1 F.Other D. Rlnseate 1. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS -� o <br /> m _`s AND Ip <br /> PRESERVATIONx <br /> � LL � Sm �� '�_� SAMPLE <br /> $o g _$ 7 *- +z '� ff r i-� m`-'�U NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDy LL I- ~� - BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> lec�5 _ tea( - r i <br /> Iv Sl3!- 3�• k <br /> �u1 0 <br /> �- � k k v-a�r <br /> NOTES 1 MISCELLANEOUS1 <br /> Relinquished by: (Signature) 11 ceiLday-.,,�Signatur6) Date Time <br /> Relinquished By: (Signature) Received By: (Signature) Date Time <br /> C)CSL{ 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 /> Send Lab Results to (Name): fit' (Check Office Below) Verbals Requested: Yes ❑ No n <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER 1LJ'OTHER <br /> TEL (404)951-0055 TEL(303) 790-1747 TEL (714) 757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL <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 ❑ ICING 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)586-9724 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 (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. I A 7 1 1 WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV.8192 <br />