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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME t"3f? f2 f)) 4= k� fR f��(�t wr Y SAMPLERS t t -FI-0 1 '-- r' SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> y <br /> 14 f! (PRINT) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER �! c�! !(f �� r 'f , f', r �, (_ A 40 ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) 13 Glass Liter E Brass Tube C Leachate H Blank/Spike 2 413 Hour <br /> RECORDER C Plastic 500 ml F Other D Rmseale I Other 3 24 Hour <br /> (SIGN). D Plastic Liter E SoillSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINEHS r, U <br /> 2 AND C <br /> PRESERVATIONv- <br /> 8g �8 zLL �• ' ; cc °� SAMPLE <br /> o m° 4+ d E 8 ° 12 NOTES ASSIGNED CONDITION <br /> E Em a = 4 �— ° BOTTLE UPON <br /> DATE TIME SAMPLE ID �r " z NUMBERS RECEIPT NOTES <br /> C1'1'0`1k, IS-50 JAW— I Irf My;v ✓ /Q�© � <br /> 1, YAW ,� t1 r/ _ r• 4" c Mtit <br /> D 3 <br /> A- n( 1` 1 h1- '5 V(/ OS <br /> G <br /> NOTES IMISCELLANEOUS ��� f�c (�F C C lYZ1) �trti,q �� ( Relinquished by (Signature) R c§Ived By (Signature) ^ Date Time <br /> T 1 - � �%,, J (-' "o- <br /> Relinquished By (Signature) Received By (Signature) Dale Time <br /> r 4 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 /> (1 fro�� Transport Container Transported with this <br /> Chain (by Serial No) <br /> �)U (z. C: V_ X1 >r fl <br /> Send Lab Results to (Name) f\t (Check Office Below) Verbais Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER f <br /> TEL(404)9510055 TEL(303) 790-1747 TEL(714) 757 1755 TEL(415) 960 1640 TEL(219) 926 6651 TEL F <br /> FAX(404) 956 9364 FAX(303) 799 0186 FAX (714) 757 0960 FAX (415) 960 0739 FAX (219) 926 7169 FAX`r-c<t � P % <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) 566-9724 FAX (713) 556-0666 FAX (215) 337-0560 FAX (510) 463 2981 FAX(503) 241 0486 FAX <br /> _CANONIE EbMRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUU 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX 03) 290-8013 <br /> SERIAL NO 7 WHITE Field Copy YELLOW t Copy PINK Laboratory Copy REV 6192 <br /> SET <br /> 1 � <br />