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�AB PROJECT ENVIRONMENTALOAIN-OF-CUSTODY RECORD <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME CW-0 TOLL- STA-0Q14 R _ SAMPLERS ABX -t-LiDez> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> t�L_ tPRI DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER Of 4�3�I job► )4 �h e-.l A 40 ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BianklSpike 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseafe I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS U <br /> ANO < <br /> am fig PRESERVATION <br /> o 8 ;i¢ s�=Y SAMPLE <br /> 22 <br /> NOTES ASSIGNED CONDITION <br /> k7, �m E > BOTTLE UPON <br /> DATE TIME SAMPLE ID co NUMBERS RECEIPT NOTES <br /> 107,1 qMW- 1 & 2 <br /> 1,021 1315- MWZ A2- + VIV <br /> 1CQ-1g6 130.5 W- A 3 , V <br /> 1021% 17255 MW-4A Ll <br /> 107-196 132 -6 <br /> I <br /> NOTES 1 MIS LLANEOUS € �a� s �` Rellnqut�h by (Signature) Revel y lgnature) date Time <br /> UjA5u po►J � 7` ' -ZZ _ 'a <br /> Relinquished By (Signature) a ived By (Signature) Date Time <br /> 1—A$ AR R \V A L <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 /> l Cham (by Serial No) <br /> Send Lab Results to (Name) J (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER MIf]L��T� <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714) 757 1755 TEL(415) 960-1640 TEL(219) 926-8651 TE —E7 7-r <br /> FAX(404)956-9364 FAX(303) 799-0186 FAX(714) 757 0960 FAX(415)960-0739 FAX(219) 926-7169 FAX —S <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) 241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX 303) 290 8013 <br />