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CANONIE ENVIRONMENTAL&AIN-OF-CUSTODY RECORD 4e PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME 111th A fa�J'� A1C Y 1)I[tf SAMPLERS E X _� rL�•� SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> p tPRINT) - DESCRIPTION CODES A Ground Waler F Oil <br /> PROJECT NUMBER (314 3-7 J 01/—/-0 -A <br /> ItL�� 6�6-hJ L7 A 40 1111 VOA Vial B surface weler G wasle I Standard <br /> (SIGN) B Glass 1 ilor E Brass Tube C Leachate N Blankl5prko 2 48 flour <br /> RECORDER _ C Plaallc son ml F Other _— n Rln9eale I Olhar-_ 3 24 liarr <br /> (SIGN) O Piaslic Lller E SolllSedlinenl _ __ 4 Other <br /> NUMBER OF _ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> u <br /> i `4 AND <br /> PRESERVATION 2 q Y— <br /> a lo E Al Iy SAMPLE <br /> L. ��� - NOTES ASSIGNED CONDITION <br /> ° BOTTLE UPON <br /> DATE TIME SAMPLE ID Z 1, <br /> rut = NUMBERS RECEIPT NOTES <br /> +029 ) MH- Iti _—✓ ,�— i�� ---- - } 1I °Y V ✓ TV gi)II <br /> �I I o2 I I e M VAI 3 -- <br /> oIi _ <br /> 11oz`}F, l�f• - 3 A �— ✓ �— / I ,� � — — -_-_ - ata <br /> ✓ 3 ✓ — 1 ✓ t� ✓ OW <br /> S <br /> 7116291, 9511 Vi- <br /> ------- --- ------ - <br /> I <br /> NOTES!MISCELLANEOUS H 5 E Relln uishedl.byb Signature) Re eived By S(gnat re) Date Tlm <br /> I- P1S /�(� ~ _ `Rlr�o�z� w1 P(:v= J1� � y U�t,��fiL� Iri <br /> U upU tJ Rollnquished By (Signature) Received By (Signature) Dale Time <br /> Relinquished By (Signature) Received By (Signalure) 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 thisMow 0-yu r <br /> Chain (by Serval Na) � <br /> tLxE <br /> Send Lab Results 10 (Name) M 1`1 Ne MS t (Check Office Below) Verbals Requested Yes El No El <br /> lATLANTA El DENVER El IRVINE ElE MT VIEW ❑ PORTER OTHER 01b'ST{) <br /> TEL (404)9510055 TEL(303) 790 1747 TEL (714) 757 1755 TEL (415)960-1640 TEL (219)926 8651 TELZOi` 7 - 7 / <br /> FAX(404) 956 9364 FAX (303) 799 0186 FAX(714) 757 0960 FAX (415)960 0739 FAX (219) 926 7169 FAX <br /> F1 BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER 1� <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 1303) 290 8336 • FAX (303) 290 8013 <br /> r inns lift — <br />