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�'CANONIE ENVIRONMENTAL AIN-OF-CUSTODY RECORD � PRoAcT <br /> (See Reverse for Instructions) NO. <br /> CA;PROJEC NAME ((����'`'E�� l�nUP�'2T V SAMPLERS f t� S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PRQ�ECT NUMBER IIL�I? f�,7�J /`� IP iNrl DESCRIPTION CODES A Groundwater F Oil <br /> A 40-ml VOA Vial 6 Surface Water G Waste 1 Standard <br /> { ; a (SIGN) B Glass Liter E Brans Tube C Leachale H alanklSplke 2 48 Hour <br /> J REF©RDER C Plastic 600-ml F Other D Rinseate 1 Other 3 24 Hour <br /> l (SIGN) D Plastic Lller E Soil/Sedimeni 4 Other <br /> 1�, CONTAINERS NUMBER OF ANALYSIS REQUESTED <br /> V LABORATORY USE ONLY <br /> ry <br /> AND t a <br /> PRESERVATION = BSS :_ <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDv+� `C ~mV�' BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> N <br /> I 5 Mw- 1 v <br /> 3 t <br /> 5 u?,Jt(,IPAL C L A h In S <br /> ----------- <br /> r <br /> sf <br /> 1 <br /> , <br /> NOTES l MISCELLANEOUS ` ��� �+ ��G�- µ TiJ ,Rel wished (Signature) R ived By Sign tore) Date T me <br /> P0 r--AP Relinquished By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chalns-Of Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> A 94 0 1-) Transport Container Transported with this <br /> Cham(by Sena! No) , <br /> Send Lab Results to (Name) O ESM A <br /> { ) (Check office Below) Verbais Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER n (7THER 1M-f) F5 <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960 1640 TEL(219)926-8651 TEL I <br /> FAX(404)956-9364 FAX(303) 799 0186 FAX(714) 757-0960 FAX(415)960 0739 FAX(219) 926-7169 FAX <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 [�6 5 3 WHITE Field Copy YELLOW Prood Copy PINI( Laboratory Copy REV W92 <br />