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CANONIE ENVIRONMENTAL SAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAMEr� ' tit'' ``I}}` " v i k' SAMPLERS F Lt I t L ' r ' SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 1 4 s (�INr) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER—(-- LC�ti `— -� A 40 ml VOA Vial 8 Surface Water G Waste t Standard <br /> (SIGN) B Glass Liler E Brass Tube C Leachate H BlanklSpike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rmseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Sod/Sediment 4 Other _ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS 11 <br /> `s AND rJ E r I <br /> r— S— PRESERVATION $— f .g 35 oy <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> 0" <br /> �,- E— c = + LL - ,- E > BOTTLE UPON <br /> DATE TIME SAMPLE ID y I- z NUMBERS RECEIPT NOTES <br /> VIV IV L/ <br /> VIVIV Vv <br /> t <br /> NOTES/MISCELLANEOUS ) '.� �+ lsy< Rellnquis ed by (Signatur ) RVelved By—{ I Nature) Date Time <br /> At-a <br /> Relinquished 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 /> Eok)CL i IZ. C00L(� IL 1-1711 <br /> Send Lab Results to (Name) 1�7 f'�N+�� �i►�St t� (Check Oft ice Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER /❑ OTHER <br /> TEL(404)9510055 TEL(303) 790-1747 TEL (714)757 1755 TEL(415) 960 1640 TEL (219) 926 8651 TELA <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) 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_ 3_00 • E_NGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290 80_13 <br /> SERIAL NO 1 A '7 i 0 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />