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CANONIE ENVIRONMENTAL 1WAIN-OF-CUSTODY RECORD �B PROJECT (See Reverse for Instructions) NO PROJECT NAME }� t )r!�' ' i t SAMPLERS ' i t , 'I SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES (PRINT) DESCRIPTION CODES A Ground water F Oa PROJECT NUMBER ,r It ' I r 1 i f '` 1 L' A 40 ml VOA Viat B Surface water G waste t Standard (SIGN) B Glass Liter E Brass Tube C Leachale H Blank/Spike 2 48 Hour RECORDER C Plastic 500 ml F Other D Rmseate I Other 3 24 Haur (SIGN) D Plastic Liter E So4lSedirnen! 4 Other NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY CONTAINERS Y ` AND m c " 8 nn am PRESERVATION 8 g� mm I ag a"Ep n _ SAMPLE 3c �a $ o a`�—' 4 I ¢4 E m`'<o NOTES ASSIGNED CONDITION 1 ' E > BOTTLE UPON DATE TIME SAMPLE ID 7 t 0 z NUMBERS RECEIPT NOTES , I NOTES 1 MISCELLANEOUS � r RQII{}gwshed by (Signature) Received By (Signature) f Date Time Relinquished By (Signature) Received By (Signature) Date Time I Relinquished By (Signature) Received By (Signature) Date Time Method of Shipment Description of Other Chains Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time Transport Container Transported with this ){ { Chain (by Serial No) Send Lab Results to (Name) f�,t 'I �`- 11,)l (Check Office Below) Verbals Requested Yes ❑ No Q ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER 10 OTHER ) TEL(404)9510055 TEL (303) 790 1747 TEL (714)757 1755 TEL(415) 960 1640 TEL (219) 926 8651 TEL FAX (404) 956 9364 FAX(303) 799 0186 FAX (714) 757 0960 FAX (415) 960-0739 FAX (219) 926 7169 FAX ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER TEL (406) 586 9496 TEL (713) 556-1666 TEL(215)337 2551 TEL(510)463 9117 TEL(503) 2410282 TEL FAX (406) 586 9724 FAX(713) 556 0666 FAX(216)337 0560 FAX (510) 463 2981 FAX(503) 2410486 FAX CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 SERIAL NO �1 {+ f' WHITE Field Copy YELLOW Project Copy PINK t aboratory Copy REV 8192 i i s