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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO, <br /> PROJECT NAME ET0Ly,T0tJ TOL I(,C SAMPLERS A LE x SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRI DESCRIPTION CODES A. Ground Water F. 011 <br /> PROJECT NUMBER _ 3�$ 01-10 ��{(� �� A. 40-ml VOA Vial S. Surrace Water G. Waste I. Standard <br /> (SIGN) B. Glace Liter E. Brea@ Tube C. Leachate H. BlankMplke 2. 411 Hour <br /> RECORDER G Plasllc .- - ; Other D. Rlnseate ;.-. (. Olhar 3-24 Hour <br /> (SIGN) D. Plasllc Lller E. Solligadlment. 4. Olher <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND y <br /> . PRESERVATION X� ➢ � ti <br /> SAMPLE <br /> ;t—NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID — x `} } ~� = BOTTLE UPON <br /> NUMBERS RE=CEIPT NOTES <br /> �08ri 0 WWF- � � A ✓ 1rI DAA ✓ <br /> —————— —————-f IS A 'HIT <br /> I <br /> Rv►� <br /> 26 <br /> iff — '- ' <br /> NOTES I MISCELLANEOUS Relinquished by: (Signature) eived By: (Signature) Date Time <br /> Scp�orA r G 13 76L <br /> Relinquished By: (Signature) Received y: (Sig ature) Dale Time <br /> Relinquished By: (Signature} Received By: (Signature) Date Time <br /> FMM�ho Shipment Description of Other Chains Of-Custody Dispatched By: (Signature) Date Tima Received for lab By: (Signa[ure) DaieTime <br /> Transport Container Transported with this��t71t.i Chain(by Serial No.) , - j'3 Z Z <br /> C.170(.' (5 3 830 <br /> Send Lab Results to (Name): (Check Office Below) Verbals Requested: Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER OTHERAMES"i'O _ <br /> TEL(404)951.0055 TEL (303) 790.1747 TEL(714) 757-1755 TEL(415) 960-1640 TEL(219)926-6651 TELS:19Z2Z( <br /> FAX (404)956.9364 FAX(303) 799-0186 FAX (714) 757-0960 FAX(415) 960-0739 FAX(219)926-7159 FAX Z� ar rT S <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)r509-9724 FAX (713)55&0666 FAX (215)337-0560 FAX(510) 463.2981 FAX(503) 241.0486 FAY :— <br /> 1PNIE 1w1 fiG VICFc 1' RP..- O Snl ITH SYnnr� SE.IAJAV SUIT 0 • Fr,rn EW('^^ L•Q nn+4f • TFr r- Vl�rr �� $ 2nn n 8 •[r �yB01^ <br /> EfiIAL N 1_ r'+ ,^ �1�—�_ •-�—..� '�"�WHIiE:Flald boy YELL -ProJ@61 Copy PINK:Laboratory Copy REV.BM2 <br />