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147-dId 5 7 5 lNc9AMME. ENVIRONMENTAL *AIN-OF-CUSTODY RECORD OPROJEC'T <br /> �- �a (See Reverse for Instructions) NO <br /> PROJECT NAME l it 1�1Aidl�'S `fit IZ Vi cz SAMPLERS ALS Tj�)f4E S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (�3 Z (00S 0001 ( fPRw ®- � � DESCRIPTION CODES A Ground Water F oil /. <br /> PROJECT NUMBER A 40 ml VOA Vial B Surface water G Waste 1,Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic SW ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plasbc Liter E SoiliSedimeni 4 Other <br /> i <br /> NUMBER OF PANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> c o AND Q, <br /> r ug PRESERVATION <br /> tz ¢ ° _ SAMPLE <br /> am � m Q� NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID ST V § u 31 j . BOTTLE UPON <br /> I NUMBERS RECEIPT NOTES <br /> t 1114 IbT Iil1� V1 Iqi o t f ✓ <br /> 0MW i t ?A <br /> Lill-4q? vJ <br /> c11 f'c.' � 5 ern►O- t r <br /> 0111,19 1177 <br /> I <br /> NOTES/MISCELLANEOUS e?m jt 0 t 1p f�4 ��: �'p� � �. Rellnquls ed-by (Signature) R celvied By t naturtje) �, �Date TI e <br /> +•. °+ j��,�'`,i b fC it F,111 D i <br /> V5I s b AL Y. C O Relinquished B (Signature) eceived B (Signature) Date Time <br /> 11i�� � R Y ( 9 ) Y ( 9 ) <br /> �t nT 9 q C� Relinquished By (Signature) Received By (Signature) Date Tlme <br /> �� VP3f� tf � �}' 7 !���'��r V <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 /> Chale (by Serval No) <br /> Send Lab Results to (Name) �� � ( (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> 1:1 ATLANTA El DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER i �i�1��? , <br /> TEL(404) 9510055 TEL(303) 790-1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL2`- <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(405)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) 2410486 FAX _ <br /> -•- -_ ---- FAX 3 <br /> CANONlE ENVIRONMENTAL SERVICES' CORP 6300 0 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 1303} 290-8336 • AX (303) 290-801 <br /> SERIAL NO +rt /� WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy - - --___ REV W92 <br />