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CANONIE ENVIRONMENTALVAIN-O -CUSTODY RECORD PRO,lECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME 111 � t SAMPLERS t 4 i u r .fit SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> J �-.! I DESCRIPTION CODES A Ground Water F Oil` <br /> PROJECT NUMBER (a + A 40 ml VOA vial B Surface water G Waste t Standard <br /> (SIGN) B Glass Liter E Brass Tube G Leachate H BlanklSpike 2 48 Hour <br /> Txy+L, , <br /> RECORDER C Plastic 500 ml F Other D Rinseaia I other 3 24 Hour <br /> (SIGN) <br /> D Plastic War E SoillSedimenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS i- <br /> AND <br /> g <br /> R-6PRESERVATION $y gg ° vY <br /> µ u , °f 9S <br /> € x SAMPLE; E Qo NOTES ASSIGNED CONDITION <br /> $` BOTTLE UPN <br /> o- <br /> DATE TIME SAMPLE ID <br /> uE9 i UMBERS RECEIPT NOTES <br /> 11/174.1 Z-) - scc-III <br /> -ri <br /> NOTES I MISCELLANEOUS _JIlnqu �d4by oignature) Received y Llgn ay ate Time <br /> S?i' f's Relinquished By (Signature) AocelvedB (Signature) Date Time 1 <br /> tfe(-h(r[t .`w,e4b�Jt CALL <br /> F" r tle-r k Relinquished By (Signature) Received By (Signature) Date Time <br /> au _5lo P r h-6 Ac Ik - U?AW Z-7cfhe, pwkA <br /> Method of Shipment Oescnphon 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 /> Send Lab Results to (Name) }�„- U y (Check Office Below) Verbais Requested Yes ❑ No ❑� <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL(404) 9510055 TEL (303) 790-1747 TEL (714) 7571755 TEL(415) 960 1640 TEL (219)926 8651 TEL % )-2Z�( <br /> FAX (404) 956 9364 FAX (303) 799 0186 FAX (714) 757-0960 FAX (415)960 0739 FAX(219) 926 7169 FAX(5:22`2=Z 5 <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) 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 � WHITE Field Copy YELLOW Project Copy <br /> PINK Laboratory Copy REV 9792 <br />