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# ItVlox <br /> ENVIRONMENTAL *AIN-OF-CUSTODY RECORD 0 PROJECT <br /> (See Reverse for Instructions) NO <br /> ,PROJECT NAME I CZ SAMPLERS ALE( 2E5 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES - <br /> Qbl (PRIN �a44,.,/ DESCRIPTION CODES A Ground water F Oil I t� <br /> PROJECT NUMBER A 40-ml VOA Via$ B Surface water G waste Standard <br /> (SIGN) 13 Glass Liter E Brass Tube C Leachate H Blank/Spike 21 oT ur r it <br /> RECORDER C Plastic 500-mi F Other D Rmseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoiliSedimeni 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS o <br /> AND ? e <br /> mm nm PRESERVATION $ N " n <br /> p� mg T_l —�Y <br /> � g LL� Sm ESAMPLE <br /> 'a e F s'ao NOTES ASSIGNED CONDITION <br /> ? nm c = LZ ¢= n 0.- <br /> t Z NUMBERS RECEBOTTLE IPT PT NOTES <br /> DATE TIME SAMPLE ID dU ° <br /> 1N 0. 5VV - � <br /> 011 z W 124 W. ( tr #OF <br /> r, t\- <br /> 311T1W MW-G V ✓ I ra ,x-4— <br /> NOTES/ <br /> 4— <br /> NOTES/MISCELLANEOUS t tilt. 01(4 Relin (Signature) pceiv-e 6{qQ.,F1at �� Q /y C q / y ( g ) y g atu } lDat TIp�'7e <br /> ft <br /> AeO � oviL j Rehn B (Si ri re) By (Signature) 1 Dat [me <br /> l �� ��/���� � �//� - L 5-C <br /> !�7 9'7 f?o� 8 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) AEANNE S (Check Office Bel ) Ve als Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER Q/OTHER " '�_� <br /> TEL(404)951-0055 k TEL(303) 790-1747 TEL(714) 757 1755 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 -�'TC <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) 2410282 TEL <br /> FAX(406) 586-9724 FAX (713) 556-0666 FAX (215) 337 0560 FAX(510) 463-2981 FAX (503) 2410486 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 (`j 1!I `'� WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />