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i'T6 A,5,5 0 c.1 ATeS I tj O-A,� n NVIRONMENTAL. CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO. • <br /> Tolls YR01?6Q_ x1 <br /> PROJECT NAME SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A. Groundwater F. oil <br /> PROJECT NUMBER A.'40-ml VOA Vial B. Surface Water G.Waste 1. Standard <br /> (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. Blank/Spike 2.'48 Hour <br /> RECORDER C. Plastic 5b0-ml F,Other D. Rinseate 1. Other 3. 24 Hour <br /> (SIGN) ;D.M Plastic Liter E. Soil/Sediment 4. Other <br /> `+• NUMBER of 'ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS v - <br /> m `o <br /> AND '_ m <br /> SAMPLE <br /> PRESERVATION $ <br /> 8Y 9Y <br /> Am �$ <br /> Sm o am .E� O a� NOTES ASSIGNED CONDITION, <br /> E- �v �= g $ °v BOTTLE UPON <br /> DATE TIME SAMPLE ID �' _ �' = NUMBERS RECEIPT NOTES <br /> d. <br /> cv-e <br /> : <br /> IreS. <br /> 3 <br /> A 1 <br /> NOTES/MISCELLA EOUS ea,� I a( - o,V V PO Y1 elinquisl�Ed Signature) Ff erv� By` e) ) �e T es <br /> t�• laiq arc r�gal ��� o.y S r,,.;cra .� �r D� / <br /> A^ Relinquished By: (Signature) Received By:(Signature), Date Time <br /> t A � <br /> + Relinquished By: (Signature) ° Received By: (Signature) Date Time <br /> VIUE 0�0 e �: pT9?c�oWa <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 �ZZ6 / �^y <br /> :Y Chain (by Serial No.) /...�.C,a[/21�-✓ 3C <br /> Send Lab Results to (Name): fe VAQ ALU, (Check Office Below) Verbals Requeste : Yes ❑ Non❑ <br /> 70 <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER e.OTHER vvE 9- <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)799-0186 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 €2 TEL(713)556-1666 TEL' 337-2551 TEL(510).463-9117 TEL(503)241-0282 TEL <br /> FAX(406)586-9724 FAX(713)556-0666 FAX P15)337-0560 FAX(510),463-2981 FAX(503)241-0486 FAX I <br /> "_.y" ENVIRONMENTAL SERVICES CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENE1jr-EWOOD CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 29u e0i3 I <br /> SERIAL NO. 14651 WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV B/92 <br />