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dMoM EMPIRNOWA H -O US�� E�R[� PART <br /> (See Reverse or Instructions N <br /> ) <br /> PROJECT NAME K N0i--M ROPE SAMPLERS A-1-ek F&0)Z 5 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> • u (PRINT)�1 / DESCRIPTION CODES A Ground waler F oil <br /> PROJECT NUMBER 9 S' 1 ta -��.�-�i.�n! A 40mt VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Llier E Brass The C Leachate H Blank/S Ike 2 4B Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseats I Olher � 3 24 Hour <br /> (SIGN) D Plaslic Lller E Soll/Sedimenl 4 Olher <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION g 3a <br /> a ¢ € ^ SAMPLE <br /> qild- < NOTES ASSIGNED CONDITION <br /> <� <br /> DATE TIME SAMPLE ID _ BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> 17 <br /> t -2v ✓ I - <br /> S <br /> I M <br /> NOTES I MISCELLANEOUS No 7,a 7fi— Relinquished by (Signature) Rature) Date Time <br /> bA*8: �Evvof A zr!!�71 <br /> �nS R/O <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 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 l0�9 <br /> Chain (by Serial No) S/Z <br /> i 1701 V21 CaDI.e f <br /> Send Lab Results to (Name) O"e (Check Office Below) Verbals Requested Yes El-No ❑ <br /> ❑ DALLAS ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER 04HER C—J- I'J9 L-Q 1J <br /> TEL(214)7701800 TEL(303)7901747 TEL(714)757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL 07 <br /> FAX(214) 770 0249 FAX (303) 799-0186 FAX (714)757-0960 FAX(415)960-0739 FAX(219) 926 7169 FAX <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 586 9496 TEL(713) 589 8686 TEL(215)337-2551 TEL(510)463-9117 TEL (503) 2410282 TEL <br /> FAX (406) 586 9724 FAX(713)531-8886 FAX(215) 337 0560 FAX (510)463-2981 FAX (503)2410486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP a TWO GALLERIA TOWER a 13455 NOEL. ROAD, SUITE 1500 • DALLAS, TX 75240 • TELEPHONE (214) 770 1600 • FAX(214) 770 0249 <br /> SERIAL NO � j 1 ,� q WHITE Field Copy YELLOW Prolecl Copy PINK Laboratory Copy REV W43 <br />