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s WNIMM WV1RMfflTA*C1fV-@ftC@WO1R RMbFW MfW13 PMCT <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME — _- SAMPLERS �' J G0AA SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q lP NT) DESCRIPTION CODES A Ground water F oil <br /> PROJECT NUMBER r �' 3 O�T A 44m1 VOA Vial B Surrace water G waste t Standard <br /> (SIGN) B Glass Liter E Braube C Leachate H BlanklSpike 2 4a Hour <br /> RECORDER C Plastic 5M Bran'Tuba <br /> F Other D Rinseata I Other 3 24 Hour <br /> i <br /> (SIGN) D Mastic Liter E SolllSedlmenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> aa aa PRESERVATION k <br /> g g r^ SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> - - .1 I- BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> T3 !Y <br /> - — <br /> A Al 1 13 <br /> 30 3 <br /> G1 P <br /> NOTES l MISCELLANEOUS etin`qui hed by (Signature) Received By (Signature) Date Time <br /> ' "� •� �K�170n •ca r�A �,� Relinquished y (Signature) Received By (SI nature a e Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) to Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> L Chain(by Serial No) <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> DALLAS ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL (214) 770-1800 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL 2 r o <br /> FAX(214) 770-0249 FAX (303)799-0186 FAX(714) 757-0960 FAX(415)960-0739 FAX(219)926 7169 FAX I t 7 r b q <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASAN70N ❑ PORTLAND ❑ OTHER r <br /> TEL(408)588-9496 TEL(713) 589-8686 TEL(215) 337-2551 TEL(510) 463-9117 TEL(503)2410282 TEL _ <br /> FAX(408)586.9724 FAX(713) 531-8886 FAX(215)337-0560 FAX(510)463.2981 FAX (503) 2410486 FAX __— <br /> CANONIE ENVIRONMENTAL SERVICES, CORP a TWO GALLERIA TOWER a 13455 NOEL ROAD, SUITE 1500 a DALLAS, TX 75240 + TELEPHONE (214) 770-1800 a FAX(214) 770 0249 <br /> SERIAL NO ,� .� 7 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy RFv tt1J1 <br />