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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT, <br /> (See Reverse for Instructions) NO._ <br /> PROJECT NAME I If 11- r_ L . �, `_ '] —; SAMPLERS! J; " SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> [PRINT}{ t DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER' It! i A. 4t),ml.VOA Vial B Surface water (1, waste t. Standard <br /> B. Glen Liter E. Brass Tubs C. Lefthate H. BlanknWke 2. 48 Haur <br /> RECORDER r,�_ +,I r' C. plastic 50u-m1 F.Other D. Shows 1. Other��. 3. 24 Hour <br /> D. Plastic Liter E. SaWSedlnwi 4. Other' <br /> [sloNl ------- — ----- <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND St <br /> PnESERYATION i i a <br /> SAMPLE <br /> F NOTES ASSIGNED UPON CONDITION <br /> AT <br /> DE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> z•rl ,t lye.:. f)i- <br /> ter• 'll I r e 1 JAI L I <br /> r r} [ t I I. j 4• I �?q <br /> NOTES!MISCELLANEOUS i Relinquiagh byt (Signature) Received By: (Signature) date Time <br /> Relinquished By: (Signature) Received By:(Signature) Date Time <br /> AtA 17) 1 1A, r + t ` i ''_` . ' ' '' Flat in wished B : (Signature)q y ( g ) , 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) r Date Time <br /> , 'If V I t I i Transport Container Transported with this <br /> Chain(by Serial No.) <br /> f <br /> Send Lab Results to (Name): (Check Office Below) •Verbals Requested: Yes ❑ No ❑ <br /> ❑ PORTER ❑ PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER _ <br /> TEL(219)92&8851 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)951.9384 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)98x1640 TEL <br /> FAX(303) 799-01813 FAX(215)337-0580 FAX 1713)556.0668 FAX(415)980.0739 FAX —� <br /> 17 CANONIE ENVIRONMENTAL SERVICES CORP. • 800 CANONIE DRIVE • PORTER, IN 46304 • TELEPHONE 219 926-8651 • FAX 219 926-7169 <br /> SERIAL No ) /I WHITE:FleW Copy YELLOW:PmJed CM PINK Labaelory Copt <br /> 4 PL t z Z� <br /> J <br />