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ILI <br /> NVIRONMENTAL&AIN-OF-CUSTODY RECORD s PROD CT <br /> (See Reverse for Instructions) NO ti i 3 <br /> PROJECT NAME SIF ( AMPLERS XI-FX q4g�ES SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> [PRINT) DESCRIPTION CODES A Ground Water F oil Ida - <br /> PROJECT NUMBER X741 �ZQ A 40 ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate N Blank/Spike 2 46 Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plast c Liter E SoillSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS INu <br /> AND <br /> m m c o PRESERVATION 6x V S <br /> � 8%_ 1 <br /> gm ¢ n8� _g SAMPLE <br /> i-� a m�aNOTES ASSIGNED CONDITION <br /> 2 1 go— BOTTLE UPON <br /> DATE TIME SAMPLE ID " h Z NUMBERS RECEIPT NOTES <br /> i -E <br /> 1- -E <br /> tA-& <br /> f - OSP-F, <br /> t7b�-E <br /> 41 <br /> r 0 7A-E <br /> NOTES 1 MISCELLANEOUS lU rr� Relinquished byJ,Slgnature)� Received By (Signature) Date Time <br /> T N4 <br /> ~ P> � 13A 01-0�7V;p PF-1 g� �� C Relinquished By (Signature) Received By (Signature) Date Time <br /> CIAO '?`(06 Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Ship ent Description of Other Chains-Of-Custody Dispatched By (Signature) Date Tlmq` Rer�ved for lab Bq�(Signature) Date Time <br /> Transport Container Transported with this 1 rt �3 <br /> Chain (by Serial No) / / O <br /> vy-d r- AL-- �7-- /I/,-,,6/7 17 <br /> Send Lab Results to (Name) (Check Office Below) V rbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA El DENVER ❑ IRVINE= LJ MT VIEW ❑ PORTER OTHER <br /> TEL(404)951-0055 TEL (303) 790-1747 TEL(714) 757-1755 TEL(415) 960-1640 TEL (219) 926-8651 TEL �, Z <br /> FAX (404)956-9364 FAX (303) 799 0186 FAX(714) 757-0960 FAX(415) 960-0739 FAX(219)926 7169 FAlf <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 /> FCANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 a FAX (303) 290-8013 <br /> SERIAL NO /* 7 1 WHITE Field Copy YELLOW Project Cagy PINK Laboratory Copy REV 6192 <br />