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ASWIfOOMENVIRONMENTAL INAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAMESTV-V'1W Titer 'Seffoff'W-^AMPLERS )e SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground water F OSI <br /> PROJECT NUMBER A 46-ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) 8 Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoillSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS e <br /> i AND ➢_ g a <br /> a $ PRESERVATIDN �^ <br /> E a SAMPLE <br /> E P4u NOTES ASSIGNED CONDITION <br /> °` BOTTLE UPON <br /> DATE= I TIME SAMPLE IDv N z NUMBERS RECEIPT NOTES <br /> 1i <br /> W- <br /> W-- 1 <br /> I <br /> NOTES!MISCELLAN OU5 ` r� _ __ —1 /� N � R Ilnqulshedyy. ignature) Received By (Signature) Date Time <br /> AlE I 13A j M B VJD I pc, g bf A� C Relinquished By (Signature) Received By (Signature) Date Time <br /> DN gib ,v �J <br /> 6AJ CA/" Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Ship ent Descnption of Other Chains-Of-Custody Dispatched By (Signature) Date TimeRego► �f r l�b�1 6(Signature) Date Time <br /> Transport Container Transported with this (� tY' /�- <br /> Chain (by Serial No) �/ 3 A <br /> 26i� - <br /> Send Lab Results to (Name) Al f"� (Check Office Below} rbals Requested eS ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER ( OTHER <br /> TEL(404) 9510055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL <br /> FAX (404)956-9364 FAX(303) 799-0186 FAX(714) 757-0960 FAX(415) 960-0739 FAX (219)926 7169 FA <br /> t9""--1zJ <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)241-0282 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 (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO 1 /i 7? 7 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />