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of <br /> CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PR&dEi <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME UT IME SIL !(�(7I SAMPLERS ' SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PR DESCRIPTION CODES A. Ground water F. Oil <br /> PROJECT NUMBER ()6-o A. 40-ml VOA Vial <br /> D. surface water 4. wast. ( 1. Standard) <br /> SI N) B. Glass Liter E. &ass Tube C. Leechete H. Blank)Spike 6 F our <br /> RECORDER C '42 _ C. Plaslk SMml F.other D. Rlnseate 1. Other 3. 24 Hour <br /> D. Mask Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND 8 Y <br /> PRE5ERViQION <br /> 1 SSS - <br /> SAMPLE <br /> - NOTES ASSIGNED CONDITION <br /> 333 BOTTLE 'UPON <br /> DATE TIME SAMPLE ID %9 Ko 1? NUMBERS RECEIPT NOTES <br /> 2 11: 0 - S7_ F <br /> t t� • r ry � � <br /> VI <br /> NOTES!MISCELLANEOUS Relinqu y: (Signature) Received By: <br /> (Signature) Dale Time <br /> ein lshed_y_(Slgnature�— G91yOd By�Signature) Date <br /> -- —�-.� <br /> Relinquished By: (Signature) Received Bf_5i nature} 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 /> (uo( . Chain (by serial No.) <br /> I <br /> Send Lab Results to (Name): 111 v (Check Office Below) Verbals Requested: Yes-f�No El <br /> ❑ PORTERPLEASANTON El IRVINE El ATLANTA El OTHER <br /> TEL(219)926.8651 / PEL(415)463-9117 TEL(714) 757-1755 TEL 1104)951-0055 TEL <br /> FAX(219)9267169 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) 960-1640 TEL <br /> FAX(303) 799-0186 FAX(215)337-0560 FAX(713)556.0666 FAX(415) 960-0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP. • B00 CANONIE DRIVE • PORTER, IN 46304 • TELEPHONE (219) 926-9651 • FAX (219) 926-7169 <br /> SERIAL NO. . -.-- _ -- .— . – <br />