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CANONIE ENVIRONMENTAL&AIN-OF-CUSTODY RECORD SB PA'OJECT <br /> (1 (See Reverse for Instructlons) NO <br /> PROJECT NAME lI�1� AIVA/`S 4Fe\11tZ SAMPLERS_/ALEX__ ZialzzS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground Water F OR <br /> PROJECT NUMBER Q 3 r3 o�'� A 40,ml VOA Vial B Surface Water G waste 1 Standard <br /> (SIGN) B Glass Litor E Brass Tube C Leachate H WanlJSpIke 2 46 Hour <br /> RECORDER C Pleallc 500-ml F Other D Rlnseate I Other 3 24 Hour <br /> (SIGN) D Plasllc Lller E Soll/Sedlment -- 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND tV Y <br /> PRESERVATION <br /> ui SAMPLE <br /> € V "a� NOTES ASSIGNED CONDITION <br /> € BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> 0 MW- Z _ ✓_ ✓ i _ � eta <br /> ! S _ V <br /> c — Z � _ .�. IC iL L��✓ <br /> NOTES 1 MISCELLANE U r--� - + / Relinquished by (Signature) Re ved By (Signature) Date Time <br /> 11107" <br /> A �,L:frJ� '071ogb <br /> Q Relinquished By (Signature) Received By (Signature) Dat Time <br /> 1 <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 /> Send Lab Results to (Name) A613hLtC 140mscy (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER R OTHER MQ 06570 <br /> TEL(404)9510055 TEL(303) 790-1747 TEL (714) 757-1755 TEL(415)960 1640 TEL(219)926 8651 TEL 7DQ-54 7251r <br /> FAX (404)956-9364 FAX (303) 799 0186 FAX (714) 757 0960 FAX(415)960-0739 FAX(219)926-7169 <br /> ❑ SOZEMAN ❑ 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)5B6-9724 FAX(713) 556-0666 FAX (215)337 0560 FAX (510)463 2981 FAX (503)241-0486 FAX <br /> CANON)E ENVIRONMENTAL SERVICES, CORP a 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 80111 a TELEPHONE 303 290-8336 a FAX 303 290-8013 <br /> SERIAL NO 1 [) R � r+ WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 6192 <br />