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�►a� CANONIE ENVIRONMENTALOHA�N-OF-CUSTODY RECORD sI <br /> y B PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NgME 57i[N. 446 ST-rT/ON 0--"SAMPLERS AGEX AW S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �I <br /> tPRINIP-^ DESCRIPTION CODES A Ground water F OilPROJECT NUMBXER 9q -3b7 !a+ jr /./ XPi✓ A 40-ml VOA Vial a Surface water G waste 1 Standard <br /> (SIGN) B Glass 1-her E Brass Tube C Leachale H BlanklSpike 2 48 Hour <br /> RECORDER C Plastic 500-m1 F Other 0 Rtnseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoiUSadunent 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATQ Y USE ONLY <br /> CONTAINERS r <br /> AND <br /> PRESERVATION T $ — d <br /> a x �y g FS SAMPLE <br /> NOTES ASSIGNED <br /> SCOBOTTLE NDITION <br /> /�DATEE TIME SAMPLE ID r � ,r y �3 = NUMBERS RECEIPT NOTES <br /> r 070 9 nod M W- I/ f �/ f/ <br /> 0 41, 3S MW- V i' i V y , <br /> M96 MW-3 A <br /> V <br /> Y?dm Mw-4 A Ar, y y -- <br /> o a W- v 3 ✓ <br /> I :✓ <br /> I � <br /> NOTES/MISC LLANEOUS Rellnquts y (Signature) Re ved By (� nature) Date Time <br /> Relinquished 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 /> l.t�V fLl Chain(by Serial No) <br /> 0 L40L 1111A -?/1t)Nk 113 <br /> ►Send Lab Results to (Name) 4�0r^SE (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER 8110THER MOI)ESTa <br /> TEL(404) 9510055 TEL(303)790-1747 TEL (714)7571755 TEL(415) 9601640 TEL(219)926 8651 TEI;Z—tl <br /> FAX (404)956 9364 FAX(303)799-0186 FAX(714) 757-0960 FAX (415) 960 0739 FAX (219)926 7169 FAX1,0215 <br /> i ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> i 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 /> „ CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290 8336 • FAX (303) 290-8013 <br /> SERIAL NO -- <br />