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M MOM M CWIR EIMROMENALWAM-0ft- UMD?%EdftDM ROM <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME CODA C oIq S%p CICT41tr SAMPLERS AA/N() ''\! 5" ffiA SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> q y _ 31 !P TI ( DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER ] � A 40-ml VOA Vial B surface water G waste 1 Standard <br /> (SIGN) B Glass Liter E Bress Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER �'ZA3} C Plastic 500-ml F Dther D Rmseste I Oth , 3 24 HourI ! 7 <{{< <br /> SIGN) D Plash Liter /!L E Soll/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> Y <br /> �-- PRESERVATfON + <br /> h SAMPLE C� } <br /> III it f oil— NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID BOTTLE UPON <br /> g NUMBERS RECEIPT NOTES <br /> Ii9� «o S it t aL , <br /> 7�,t 11a f wh! l <br /> 4R, �ocici>� <br /> NOTES t MISCELLANEOUS a shed by ( ture} WR <br /> S}nature Date TI�" �` �� <br /> R inqu h y (Signature) C lve By ( gnature) Date Time <br /> C r � 2 <br /> Relinquished y (Signature) ecei d By (Signature) Date Timct <br /> Method of Shipment Description of Other C - f-Custody Dispatched By (Signature) ate Time ece ed for lab By (Signature) Date Time <br /> Transport Container ported with this <br /> Chain (by Serial No) <br /> �Tendra-5—Reis—ults to (Name) ''QAnhe ��OmsQ `)iD ?Y1 t`� '(Check Office Be Verbals Requested Yes El No ❑ <br /> ❑ DALLAS ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTEROTHER c CrX110ti <br /> TEL(214) 770-1800 TEL(303) 790.1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219)926 8651 TEL a 09-g 7()l <br /> FAX(214) 770-0249 FAX(303) 799-0186 FAX(714)757-0960 FAX(415)960-0739 FAX(219)926-7169 FAX a e ol S 3 V 75'09 <br /> ❑ BOZEMAty ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406) 586 9496 TEL(713) 589-8686 TEL(215)337-2551 TEL(510)463-9117 TEL(503) 241-0282 TEL <br /> FAX(406) 586-9724 FAX (713) 531-8886 FAX(215)337-0560 FAX(510)463-2981 FAX(503) 2410486 FAX <br /> r e� NONIE ENVIRONMENTAL SERVICES, CORP • TWO GALLERIA_TOWER • 13455 NOEL ROAD, SUITE 1500 • DALLAS, TX 75240 • TELEPHONE (214) 7701800 • FAX(21_4) 770-0248 <br /> SERIAL NO 9 1 1 9 h WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 11193 <br />