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{ <br /> I <br /> CANONIE R 1 n 5 1 S o ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD t=;41H PRO.EGT- <br /> , <br /> ( Reverse for Instructions) No. <br /> PROJECT NAMiE t-0SAMPLER SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> `d it STI DESCRIPTION CODES A.Ground WMw F.O+ <br /> PROJECT NUMBER <br /> — !A- � IL 40�4 vaA vw B.S;atran Wal O.will1. <br /> ISrON� B.ii Urr IE.A Tube C.l.Cal H-all r� <br /> RECORDER r C.Pill 540..4 F.Ol D-ssrnesM. I.Oth. 3.24 ew. <br /> D.Ftrre"wE.udV'Jwjbnent 4.Op+w <br /> NUb"ll of ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> All ;' <br /> $Fr�.�sata+ SAMPLE <br /> iTPR <br /> 3 _ NOTES ASSIGNED EE CONS N <br /> DATE TIME SAMPLE IQ 3 V 2 NUMBERS RECEIPT <br /> NOTES <br /> O7-S - L 1 dQ P. o . <br /> F <br /> 'i <br /> NOTES 1 MISCELLANEOUS Reli (Signature) Received By:(Signature) Date Time <br /> Relinquished By:(Sigiature) Received By-.(Signature) Date Ti <br /> Rett t3y (Sigtlalura) Received By:(Signature) Date Time <br /> I <br /> k ' <br /> Method of Shipment Description of Will Chains•Of-Custody Dispatched By.(Sianaturo} Date Tut10 Rxe[ved for tab By,(Signature) Data Time <br /> Transport Container Transported with this <br /> C4�O Chain(ny Sarial tai.) i7. <br /> 0 C7 <br /> __. . Send Leh Results to(Name): _ �� GO �"T-" (Cheek Office Below) Verbals Requested: lYes ❑ No ❑ <br /> ❑ PORTEH PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <br /> ter• <br /> TEL(215)928.8651 TEL(415)453-9117 TEL(714)757-1755 TEL(404)95t-0055 TEL <br /> FAX(219)926.7169 FAX(415)463-2981 FAX(714)757-096[r FAX(404)951.91 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT.VIEW ❑ OTHER 7 <br /> TEL(303)790-1747 TEL(215)337.2551 TEL(713)556-1666 TEL(415)960.1640 TEL <br /> FAX(303)7990186 FAX(215)337.0.560 FAX(713)556.0665 FAX(415)91 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP. • 800 CANONIE DRIVE •PORMR, IN 46304 •TELEPHONE(219)926-8651 • FAX(219)926.7169 <br /> SERIAL NO 12265 --- - WHITE:Fkb Copt YELLOW-li Call Pri tabanl Y Cw, <br />