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m merm mcAMN FUM EffAL'%A1r-4FP-&S"8DI"flEdT%D' drPROJECT <br /> ) (See Reverse for Instructions) NO <br /> PROJECT NAME 79160111791601791601111V,11/3j�QV'IC(' SAMPLERS ALEX 7 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT) +-� DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER T A 40-mg VOA Via! a Surface Water G Waste t Standard <br /> (SIGN) a Glass Liter E Gras•Tube C Leachate H Btank/Splke 2 48 Hour <br /> RECORDER C Plastic 500-mi F Other D Rlnsante 1 Omer 3 24 Hour <br /> (SIGN) D Plastic Liter E SoitlSedlrnent 4 Olhar <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVAri N _ H <br /> SAMPLE <br /> $ _ { �� NOTES ASSIGNED CONDITION <br /> I, <br /> t} BOTTLE UPON <br /> DATE TIME SAMPLE IDIIIT z z NUMBERS RECEIPT NOTES <br /> Z .;- I A A 13 , t <br /> 130 A A3 I <br /> Z 3 <br /> 04 W4 il 3 AMZ <br /> 235' y u <br /> NOTES l MISCELLANEOUS Relin wished b (Signature) a eived B S nature <br /> q Y ( 9 ) Y ( 9 Date Time <br /> 1 r <br /> EIi3r 1?+r u ISI) /�111fL�f: 0 ,� 16,DS" <br /> /-A 8 ir1FE2rt i� (�f7Q/v Rehnquished 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 /> to�� _C Chain (by Serial No) `1 4 <br /> Send Lab Results to (Name) r~ (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER 2/OTHER TDD <br /> TEL(404) 951-0055 TEL (303) 790.1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL <br /> FAX(404)956-9364 FAX(303) 799-Ot86 FAX(714) 757-0960 FAX(415) 960-0739 FAX (219) 926.7169 FAXZ*j:V -IZZ <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 588-9496 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 2961 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 /> SERIAL NO 1 5 7 1 7 WHITE Field Copy YELLOW Protect Copy PINK Laboratory Copy REV 8192 <br />