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[ C t t C C C C [ [ C C [ C [ t t C C <br /> A-TC ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> n (See Reverse for Instructions) NO. _ <br /> PROJECT NAME � �►�Gp � SAMPLERS )4i't R4"4 / SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT) DESCRIPTION CODES A. Ground Water F. oil <br /> 5 A. 40-m1 VOA Vial B. Surface Water G. Waste 1. Standard <br /> PROJECT NUMBER <br /> �\f�tp� +�Q (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. Blank/Spike 2. 48 Hour 1 <br /> RECORDER krt`�" `� A`",� C. Plastic 500-m1 F.Other D. Rinseale 1. Other 3. 24 Hour -- <br /> (SIGN) <br /> D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY _ <br /> CONTAINERS v <br /> `4 AND S c_g $,ng—g PRESERVATION 8 y `� m <br /> 88 8� FS i SAMPLE <br /> �E N NOTES ASSIGNED CONDITION <br /> E _ LL� t E ° BOTTLE UPON <br /> DATE TIME SAMPLE ID z NUMBERS RECEIPT NOTES <br /> �1�tf 3 3} at. t;J r✓11_ I qd<< -- <br /> NOTES/MISCELLANEOUS L-M! W n Ito UA-- R Inquish : (Signature) Received By: (Signature) Date Time <br /> n A( c� <br /> Ur <br /> 1 r ct, AP Q (lir I(A'%A 11 "A t Relinquished B (Signature) Received B (Signature) Date Time <br /> 1 � � t � r q Y� ( 9 ) Y� ( 9 ) <br /> 'k'A t=-TII - <br /> p� Relinquished By: (Signature) Received By: (Signature) Date Time <br /> PfQLC QJC1� Ci`o�`7L — <br /> Method of Shipment Description of Other Chains-Of-CustodyDispatched By: (Signature) Date Time Receive for lab By: Si natt e) Date Time <br /> Transport Container Transported with this O'r In <br /> Chain (by Serial No.) <br /> /l <br /> Send Lab Results to (Name): by" c%v\ A\U A (Check Office Below) V rbals Requested: Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER OTHER A'o3 jA) .- <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219) 926-8651 TELZ 2Lt <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 /> 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 n WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV ar92 <br />