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[ LAB PROLCT <br /> t ` ,C�gr�1.�N�€ EN�IRO�MENTAL CHAIN-OF-CUSTODY RECORD <br /> (See Reverse for Instructions) 3g (tc,n NO.9 Z//2 2 - <br /> 1Z-3 s-Z _ <br /> PROJECT NAME ?anPrE R-1-1 SAMPLERS—ALEEX SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �/� o (PRINT) DESCRIPTION CODES A. Ground Water F. oil <br /> ( ��,''�, <br /> PROJECT NUMBER I O-9-E-4-- OM-3 A Q _ �� .A Q -A. 40mlVOA Vial ' B. Surface Water G. We % I. Standard(rl <br /> (SIGN) B. Glass Liter E. Brass Tube�1 C. Leachate H. Blank/Spike l -2. 9 1io-ur_- <br /> RECORDER C. Plastic 500-m1 F.Other Ay D. Rinseale I. Other 3. 24 Hour <br /> (SIGN) 0. Plastic Liter E. Soil/Sediment _ 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS '— <br /> i AND $— a— <br /> C-- — PRESERVATION A a <br /> �gg gg _ Q-a. � <br /> 8B LL 8m I SAMPLE <br /> a� $€ _ -� p- x , q QO y NOTES ASSIGNED CONDITION <br /> IL w a �� BOTTLE UPON <br /> DATE TIME SAMPLE ID 3^ = NUMBERS RECEIPT NOTES <br /> ! - C At -F <br /> NOTES/MISCELLANEOUS 1 Relinquished by: (Signature) Received By: (Sign lure) Date Time <br /> REOCIRT ONLY um '�2.G0: 7-?- <br /> -A�) Ned 'TgA I NTI-6E 1 D�p E ruT Relin ed B (Signature) eceived B Si nal d) / ate �1 Time <br /> �"Tr�ME v� ( s ) v� ( g <br /> (-ox IC-1I-PJKFV'n, 1::,j C- tr Aba1ri✓rrs). <br /> Relinquishe y: (Signa ure) Received By: (Signature) Date Tim <br /> It LC—0 T- t <br /> Method of Shipment Description of t er Chains-Of-Custody Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> Transport Container Transported with this p <br /> ho &1 ,3(z I C- Chain (by Serial No.) <br /> y tog 6 t- )"I b "/,7l(o 5 <br /> Send Lab Results to (Name): _T)V Fir' VAW A, I r (Check Office Below) Verbals Requested: Yes 11No El11ATLANTA ❑ DENVER ElIRVINE ❑ MT. VIEW ElPORTER ti}'/OTHER MODESZ <br /> TEL (404)951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL 2> -,IT79 ZZZ•� <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 ❑ KING 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 /> ENVIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 .• TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. /� r WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REv 8192 <br />