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CANONIE ENVIRONMENTAL &AM1N-OF=-CUS=T0DY=REC=0RD= PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME a!(iCGY11'P� _ SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground Water F Od <br /> PROJECT NUMBER r3 —49 A 40-m1 VOA Vial B Surface water G waste t Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER c Plastic 500-m1 F Other D Rmseate 1 Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoillSedirnent 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> g AND F <br /> PRESERSIATION <br /> x 8 SAMPLE <br /> Z kU m NOTES ASSIGNED CONDITION <br /> E— - � AQ - > BOTTLE UPON <br /> DATE TIME SAMPLE ID C12 NUMBERS RECEIPT NOTES <br /> 1 <br /> tr I <br /> Y <br /> 15 <br /> 5 <br /> .S <br /> X <br /> kx <br /> - S � <br /> kIt <br /> . X <br /> 835;s <br /> NOTES 1 MISCELLANEOUS inqulsby (S nature) R Ived By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Ply hid <br /> 11 Q I r Relinquished By (Signature) Received By (Signature) Date Time <br /> I <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 /> Chain (by Serial No) <br /> 1 �3 <br /> Send Lab Results to (Name) VA L.C. _(f'i$ (A (Check Office Below) Verbals Requested Yes No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER -QS <br /> fQ <br /> TEL(404)951-0055 TEL(303)790.1747 TEL(714)757-1755 TEL(415) 960-1640 TEL(219)926-8651 TE <br /> FAX(404) 956 9364 FAX(303)799-0186 FAX(714)757-0960 FAX(415) 9600739 FAX(219) 926-7169 FAX j§ <br /> �Z2ZS <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 /> SERIAL NO -1 A r- n A WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />