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CANONIE ENVIRONMENTAL *AIN-OF-CUSTODY RECORD & PROJECT+ <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME ii it M A r.1 S <�E V�t C E SAMPLERS �E x f��u a r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �y !/I 9, ,'iPRiru� DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER ��f 0f!_!_n �j"�'>F-� itL�'�� A 40mIVOAVIaI a Surface Water G Waste I Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachale 11 Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 5110 ml F Other D Rinseale I other 3 24 Hour <br /> (SIGN) D Plastic Lrler E Sell/Sedlment _ 4 Other__ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS u <br /> AND 8_ " <br /> - S- PRESERVATION Y_ " <br /> § e <br /> SAMPLE <br /> $ �€ o x I� " �� NOTES ASSIGNED CONDITION <br /> �1 4 to BOTTLE UPON <br /> rATTIME SAMPLE ID _ } "� NUMBERS RECEIPT NOTES <br /> 340 - I V ✓ I a 5 V ✓ 0 VicI 012AA ✓ � I ✓ g 013 <br /> {r:, w- A Ac �32� �� P ��3 ✓ � ✓ ✓ o�� <br /> �'ab29C� 3t vW—(o A 61� _ <br /> R <br /> NOTES I MISCELLANEOUS -� r Roll n uished by Signature) Rle�etved By Signal re) (Date To <br /> X111�' I C 5 E �Rlr ov_t) Ln M PU bw Ul .� � (� i I`IG V <br /> ��0 r" T V"(It IZAI U(Lc v p o o 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 /> Send Lab Results to (Name) M i`I E MS (Check Office Below) ' Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER 01E STC} <br /> TEL(404)9510055 TEL(303) 790-1747 TEL(714) 757-1755 _TEL(415)960-1640 TEL(219) 926-8651 TEL?-07f`57 - z ! <br /> FAX(404)956 9364 FAX(303)799 0166 FAX(714) 757-0960 FAX(415)9604739 FAX(219)926-7169 FAX 7 09- -z22YS <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 a 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 80111 • TELEPHONE (303) 290 8336_0 FAX (303) 290 8013 <br /> SFRIAL NO 1 , WHITE Field Copy YELLOW Prn<ect Copy PINK Laboralory Copy FIFV &q7 <br /> 11 .1 i <br />