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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> l/J fl See Reverse for Instructions) NO <br /> PROJECT NAME SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PRINT) DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER) A 40 ml VOA Vial B Surface water G waste t Standard <br /> 5 N) 1 B Glass Liter E Brass Tube C Leachate H etank/Spike 2 49 Hour <br /> RECORDER C P;asbc 500 ml F Other o R nseale I Other 3 24 Hour <br /> {SIGN) D Plastic Liter _ E SoilfSedimeni 4 Other <br /> I <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND a Zr 8 A <br /> E B PRESERVATION $� a$ <br /> ? <br /> J� Cr C(� g a8 g u E E a ax =g SAMPLE <br /> O a� 6= E1 o°<� NOTES ASSIGNED CONDITION <br /> E– – n = LL~ �� °V BOTTLE UPON <br /> DATE TIME SAMPLE ID _ = NUMBERS RECEIPT NOTES <br /> 1JvW 13 <br /> S•�a `l`'`am 3 1 <br /> r — <br /> 1 <br /> NOTES 1 MISCELLANEOUS �4 R nq ed by�gna e) Receive By (Sig �u ale Time <br /> d (Signature) ijeJ By (Signature) Date Time <br /> � '[ —� , ✓N1 1�1�1 ` Relinquished By (Signature) Received nature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Asp t hed By ((Sigtur� Date Time Receive for ab By (Signature) Date Time <br /> Transport Container Transported with this <br /> �� Chain (by Serial No) y/6 <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes ❑ N Six <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 FAX <br /> ❑ SOZEMAN ❑ 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 /> CANON IRONMENTAIL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, RL&TE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FA 303) 290 8013 n <br /> IALI!IIWr Field ft YE -iecl'i PINK.Laboratory WE =O <br />