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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAE PRO. 1 <br /> /1 (See Reverse for Instructions) NO 95 1 I/1 <br /> PROJECT NAME Ob f�1 SAMPLERS—10V11 r`Ltyl^ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> _ //,. D DESCRIPTION CODES A. Ground water F. Oil <br /> PROJECT NUMBER 3`� A. 4aml VOA Vial B. Surlace Ware, 0. Waste 1. Standud <br /> //�]A (SIGN) B. Glass Liter E. Bruse Tube C. Leachate H. Blankaptee 2. 4a Hour <br /> RECORDER "'aGe.+gL1. C. Plastic 500.m1 F.Omer D. Rlnxale I. Other- 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. SoIVSedlmenl 4. Omer <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> 5 AND <br /> PRESERVATION It p 39'p a <br /> SF a9� 4 qs E �6 4 SAMPLE <br /> ,i§jI NOTES ASSIGNED CONDITION <br /> BOTTLE UP <br /> DATE TIME SAMPLE ID <br /> "" i y NUMBERS RECEEIIPT NOTES <br /> T - 3D E 1it< 1 1 <br /> -Z^ 2.S EC1 xx 1 <br /> — <br /> E l )c <br /> NOTES MISCELLANEOUS quish (Si azure) R ce' By:-(81 atuate CT� <br /> LTLcf <br /> Iinqulshed By: Signature) 116c d By: (Signature) ate Ti <br /> efnquished By: (Signature) Received By: (Signature) Date a <br /> Method of Shipment Description Of Other Chains-Of-Custody Dispatched By: (Signature) Date Tlme Received for lab By: (Signature) Dale Time <br /> Transport Container Trensporied with this <br /> IChain(by Serial No.) <br /> - - )�- //-/P-9 ld30 <br /> Send Lab Results (o (Name): (Check Office Below) Ver Requested: Yes PTINo ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER ZOTHEFI 11a _ A <br /> TEL(404)951-0055 TEL(303) 790.1747 TEL(714) 757-1755 TEL(415)960.1640 TEL(219)926-8651 20 <br /> TEL TEL 2]-'L <br /> il <br /> w l <br /> FAX(404) 956-9364 FAX(303) 799-0186 FAX(714) 757-0960 FAX (415) 960-0739 FAX(219)926-7169 FAX Cn-2Z _ <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. a 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD CO 80111 a TELEPHONE (303) 290-8336 a FAX (303) 290-8013 <br /> SERIAL NO 1 c: ^ O n WHITE',Field Copy YELLOW.Prolad Copy PINK.Laho,abry Copy REV a. <br />