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CANONIE ENVIRONMENTAL41HAIN-OF-CUSTODY RECORD IDAB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME .. r2fi.tVr-rl ;? r J�i t_� SAMPLERSSAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT)_„_ DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER r - e4—lo— � �, a , J A 40 mi VOA Vial B Surface Water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500 mi F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soil/Sediment T1 4 Other <br /> NUMBER OF ANALYSIS REQUESTED <br /> LABORATORY USE ONLY <br /> CONTAINERS <br /> U <br /> m `o AND <br /> y m §g PRESERVATIONSAMPLE <br /> S �8 <br /> T-- �r <br /> G � m° �m m NOTES ASSIGNED CONDITION <br /> emoNe } BOTTLE UPON <br /> DATE TIME SAMPLE IDm z NUMBERS RECEIPT NOTES <br /> tti 7 / jA, V1 <br /> ZU - ! .f/ <br /> y ' 4Al I-4103 <br /> of 1r I� / S <br /> oil <br /> t-- <br /> NOTES 1 MISCELLANEOUS Relinquished by (Signature) Received By (Signature) Date Time <br /> fLf <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 /> N V—(-)U 0 Chain (by Serial No) <br /> Ch. 10 19- <br /> dA <br /> Send Lab Results to (Name) ''r'0 fj 1 Z (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER ✓ OTHER 1, )[-,')-/0 , <br /> TEL(404) 951-0055 TEL(303) 7901747 TEL(714) 7571755 TEL (415)960-1640 TEL (219) 926-8651 TEL2 T`�-=-�'"I <br /> FAX(404) 956-9364 FAX(303) 799-0186 FAX (714) 757 0960 FAX(415) 960 0739 FAX (219)926-7169 FAX y <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 5B6 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 /> I CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO !� I WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br /> I <br />