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PROJECT, <br /> CANONIE ENVIRONMENTAL GAIN-OF-CUSTODY RECORD _ <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME -11 1- SAMPLERS / t _ r- SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (P INT) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER f t9 ' _ ' x 3 f A 40 ml VOA Vial B Surface Water G waste 1 Standard <br /> � �" (SIGN) B Glass Lder E Brass Tube C Leachate H BlanWSpike 2 48 Hour <br /> C Plastic 6Wm1 F Other ❑ Rmseate I Other 3 24 Hour <br /> RECORDER D Plastic Liter E SodlSediment 4 Other <br /> (SIGN) <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> m a AND <br /> 5^ PRESERVATION m <br /> GS w g LL i f g E E� o f L SAMPLE <br /> 3 m o m z _ �` E F ;"a� NOTES ASSIGNED CONDITION <br /> E <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID �' N y z NUMBERS RECEIPT NOTES <br /> 4,14A V t <br /> c ' 17 <br /> 0G <br /> r _FFTQ <br /> I J <br /> NOTES 1 MISCELLANEOUS Relinquished by (Signature) Received By (Signature)Date Time <br /> { tv�ntw[sr4�i'I f �.1 , <br /> L R`i'; Relinquished By (Signature) Received By( gnat e) a e Ime <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 1\ <br /> Method of Shipment Description of Other Chains-Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> {y ,(� Transport Container Transported with this <br /> M( Chain (by Serial No) <br /> Send Lab Results to (Name) - - (Check Office Below) Verbals Requested Yes ❑ No El <br /> ❑ ATLANTA ❑ DENVER ElIRVINE ElMT VIEW ElPORTER OTHER <br /> TEL (404) 951-0055 TEL(303) 7901747 TEL (714) 7571755 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) 566 9496 TEL (713) 556-1666 TEL (215) 337-2551 TEL (510) 463 9117 TEL (503)241-0282 TEL I <br /> FAX (406) 586-9724 FAX (713) 5WO666 FAX (215) 337-0560 FAX (510)463-2981 FAX(503) 241-0486 FAX <br /> CANONfE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8REV <br /> 8142 <br /> WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy <br /> REV <br /> SERIAL NO � N �. .t � <br />