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McARbOr t Eff&LftAff-OFT- JSTD?TEG%D M M @FAOJR <br /> 1 <br /> (See Reverse for instructions) NO <br /> PROJECT NAME ✓� f1 iS SAMPLE Wi'l111�wt f�CL"t (K SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> L1/_ 3 IP 17 DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER f 7 A 40-m1 VOA Vial B Surface Water G Waste 1 Standard <br /> ' (SIGN) a (class Liter E Bross Tube C Leachate H BlankfSpike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rmseate I Other 8 24 Hour <br /> (SIGN) D Plastic Liter E SoiUsediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> �— PRESERVATION €: + <br /> LL SAMPLE <br /> it it $ i NOTES ASSIGNED CONDITION <br /> DATE TIME V y ~ � BOTTLE UPON <br /> SAMPLE ID NUMBERS RECEIPT NOTES <br /> 5- 2.5;5 - x <br /> NOTES 1 MISCELLANEOUS hryqu by Ignature) Received By Stgnatur ) Date Time <br /> elinquished By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <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 <br /> Chain (by Serial No) <br /> Send Lab Results to (Name) J; <br /> ( ) 5 (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTEROTHER <br /> TEL(404)951-0055 TEL(303) 790.1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TE $3fI' 76 <br /> FAX(404)956.9364 FAX(303)799-0166 FAX(714)757-0960 FAX(415)960-0739 FAX(219)926-7169 FAX 38' I7 <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)5869724 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 15528 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8162 <br />