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C C [ [ 1 [ 1 <br /> - IE ENVIRONMENTAL CHAIN—OF—CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) No. <br /> PROJECT NAME SAMPLERS rt h �5��_ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q�c (PRINT) DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER O / A. 40-m1 VOA Vial S. Surface Water G. Waste 1. Standard dq <br /> 1 ) U A (SIGN) S. Glass Liter E. Brass Tube C. Leachate N. 131ank/Spike 2. 48 Hour <br /> R <br /> RECORDE \A/ VckV1� C. Plastic500-fnl F.Other D. Rlnseate 1. Other 3. 24 Hour <br /> (SIGN) D. Plasllc Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION <br /> s SAMPLE <br /> _ — F — NOTES ASSIGNED COUPON N <br /> DATE TIME SAMPLE ID Z NUMBERS RECEIPT NOTES <br /> U IA—E <br /> F1 <br /> NOTES/MISCELLANEOUS . 1 p R in wished by: (Signature) R ceiv B <br /> fV pZ(p� , r��opt- oN1y q y ( g ) ftd Y' (Signature) Date Time <br /> 1 <br /> AJ o►c� �I� A i Pe �E °-- - <br /> r 701 /M�tr Relinquished By: (Signature) eived B : Sign ure) Date Time <br /> Relinquished By: (Signature) Recelved By: (Signature) Date Time <br /> LIff <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 ��P Gi N-T ��, ,mss <br /> Chain (by Serial No.) /' p f <br /> Send Lab Results to (Name): ICU (Check Office Below) Y ball Requested: Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER OTHER /4!0 10 <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)799-0166 FAX(714)757-0960 FAX(415)960-0739 FAX (219)926-7169 FAX 2g'i , yj— �- <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 /> CANONIE ENVIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY SUITE 300 • ENGLEWOOD CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290 8013 <br /> SERIAL NO. 1 a'I ^ q ^ WHITE.Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV.8Yt2 <br />