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CANONIE ENVIRONMENTAWHAIN-OF-CUSTODY RECORD AS PROJECT <br /> S �c�ck:n (See Reverse for Instructions) NO 9GOG L�3 <br /> PROJECT NAME"� k SAMPLERS '''' j G v nix; SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> i�F�INT) r(rT��'�t DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER , ' rte ` A 40-.1 VOA Vial B Surface water G Waste 7 Standard <br /> (SIGN) B 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 Pies,rc Liter E SoillSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> 8 AND o B <br /> $—sg PRESERVATION o^ g #S <br /> SAMPLE <br /> $� $ Z w 9 r �_ "` NOTES ASSIGNED CONDITION <br /> z LL t V>— BOTTLE UPON <br /> DATE TIME SAMPLE ID '4 r { �` NUMBERS RECEIPT NOTES <br /> ,r?U 9T 5 S tx 1 AI? I i <br /> y 5 S- fit Aw A t' -- <br /> I`I!S S'{ r /� M4v K� A, t t ' t7S <br /> r 1 <br /> NOTES t MISCELLANEOUS ��3� �-relio-qutlshed by`'(Signature) RecelvedjBy (Signature) Date I i T,Irper <br /> rr +A?� G� „ :, IAN". ._ ` 1 • 7 1 <br /> R I utshedJBy (Signature) Recel ed By (Signature) Date Time <br /> r <br /> el nquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-CustodyDispatched By (Signa(ulo Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this r <br /> Cham (by Serial No) Cj f <br /> 3r rqs �(p J� <br /> I <br /> Send Lab Results to (Name) _f !� �' `'� �'' (Check Office Below) erbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER 1J 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 FAX <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 /> SE91AL NO ! WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 6192 <br /> h - <br />