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A=AhIONIE-ENVIRONMENT-AL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) -z//s_ NO..Z <br /> ,�%T NAME 1 c ,�v��r `� SAMPLERS <br /> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PR NT) DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER-$OQ3 <br /> Q QQrl <br /> —T _ A. 40-ml VOA Vial B. Surface Water. G. Waste 1. Slander <br /> (SIGN) B. Glass Liter E. Brass Tube C. Leachate H. Blank/Spike <br /> RECORDER \UWP "\�+c \\lC��� C. Plasllc 500-m1 F.Other D. Rinseata 1. Other 3. 24 flour <br /> (SIGN) D. Plasllc Liter E. So1VSedlmenl 4. Other <br /> NUMBER OF ANALYSIS REQUESTED <br /> CONTAINERS LABORATORY USE ONLY <br /> AND <br /> PRESERVATION Yj–{ y gk 3 <br /> r3 S IYii! y -�' 33a <br /> o–F 015 x80 SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID ' 0 Il i~ g BOTTLE UPON <br /> NUMBERS RECEEIPT NOTES <br /> f 11 C — <br /> _ _I -- <br /> - :22 .6 <br /> 944 I - - <br /> I! <br /> NOTES/MISCELLANEOUS }� Relinquished by: (Signature) aee ived B nature) Dale Time <br /> Act 1 ��.� �^' Y✓� ^ti I/Ll-M-7- 21 2 C�'7i I <br /> Re In ui ed B SI nature eceived B SI nor ure Date Time <br /> Y: ( 9 ) Y: ( 9 ) <br /> Relinqulsh By: (Signature) Received By: (Signature) Date Time <br /> pr•IC.- QG+c.. QT a <br /> Method of Shipment Description of Other Chalns-OI-Cuslody Dispatched Illy: (Signature) Dale Time Received for lab By: (Signature) Dale Tlme <br /> Transport Container Transported with this <br /> Chain (by Serial No.) / 3 S <br /> ErJ Co�2� c Q- Looe (� �q t., �y7 � �� '� ASW", <br /> Send Lab Results to (Name): .o Vc.�, /�,\��•.^ <br /> (Check Office Below) Verbals Requested: Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER ] OTHERtY�c�Ic st .a <br /> TEL(404) 951-0055 TEL (303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL.7 on S`La:�l 221 <br /> FAX (404) 956-9364 FAX (303) 799-0186 FAX (714) 757-0960 FAX (415)960-0739 FAX (219) 926-7169 FAX 7 m Z22{ <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 /> CA140NIE ENVIRONMENTAL SERVICES, CORP. 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. 14692 <br /> 1 WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV.u:92 <br />