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M MVM MCA]NTFEMNOMEIMAL%A -OFP.&STBDY"RECMD M 4rBROI <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME )11ifM1g1—VW:x -SnUICE SAMPLERS h1 UrX IZQIF-ES SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (}!, r�+� ���IPyRINT}�� — DESCRIPTION CODES A Groundwater F ou <br /> PROJECT NUMBER T 1Y -X71 /`�'�—�Gr1(� / A 40 ml VOA Vial B Surface Water G Waste t Standard <br /> (SIGN) B Glass Liter E Dress Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER (SIGN) <br /> Plastic 500 nI F Other D Rinseale t Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SollfSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PFIESEFRVA1 y zyg a _ <br /> SAMPLE <br /> - NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> Z Z t�� ✓ Dh <br /> ( -,Z A I <br /> Z 2 <br /> _ v <br /> 3 1 v <br /> 01 Zi 75- v <br /> NOTES I MISCELLANEOUS Relinquished by (Signature) a lived By ( gnature Date Time i <br /> LA , ARu�j <br /> P(.r.�a� I�Euj�� S�tr�Rr: oily 1 :05 <br /> 6 ' EGZ vr2.� 0,00AJ Relinquished By (Signature) Received By (Signature) Date Time <br /> Arz,/ I Vim" Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Descnptl n of Other Chai -Of-Custody Ispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) 0/12g6 <br /> Send Lab Results to (Name) J C m✓ I (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ QFNVER ❑ IRVINE j ❑ MT VIEW ❑ PORTER OTHER #01067%M <br /> TEL(404) 9510055 TEL(303)790-1747 TEL (714) 7571755 TEL(415)960-1640 TEL(219)926-8651 TEL -, 1 <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX (714)757-0960 FAX(415) 960-0739 FAX(219)926 7169 FAX-Z -7ZZ 5' <br /> ❑ BOZEMAN ❑ 1iOUSTON ❑ KING OF PRUSSIA + ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL (406) 586 9496 TEL(713) 556-1866 TEL(215)337-2551 TEL(510)463-9117 TEL(503)2410282 TEL <br /> FAX(406)588 9724 FAX(713) 556.0666 FAX(216)337-0560 FAX (510) 463-2981 FAX(503)2410466 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP - 6300 SOUTH SYRACUSE WAY,)SUITE 300 - ENGLEWOOD, CO 80111 a TELEPHONE 303 290-8336 - FAX 303 290-8013 <br /> SERIAL NO 1,9717 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />