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= M IM M M = skm M M M M = a <br /> CANONIE ENVIRONMENTAL AIN-OF-CUSTODY RECORD PROJECT <br /> TI m 0' f SI A-e— Ass s-s, (See Reverse for instructions) NO <br /> PROJECT NAME ';- C SAMPLERS 6, A SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES � <br /> f �/! 4 (PRIN DESCRIPTION CODES A Ground Water F til <br /> PROJECT NUMBER_. C7 I J / A 40-ml VOA Vial � B Surface water o Waste —t mandard T <br /> c.._ (SIGN) B Glass Liter E .T C Leachate H Btank(Spike 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other DD Wnseats <br /> 4 Other 3 24}lour � <br /> (SIGN) D Plastic 1-Her4 Other <br /> NUMBER OF ANALYSIS REOUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND Y <br /> PRESERVATION p II <br /> III SAMPLE <br /> F - NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDvT 'U ~ BOTTLE UPON <br /> Jo 51t7 NUMBERS RECEIPT NOTES <br /> �S , 0 fi <br /> .0 i5 k <br /> r <br /> NOTES/MISCELLANEOUS Relinquished by (Sig re) Rne <br /> i y' g a re _ Y Da i <br /> ' Relinquished By (Signature) ry By (Sig t r ) D to Time <br /> 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 /> Transport Container Transported with this <br /> ! Chain (by Serial No) <br /> • <br /> Send Lab Results to (Name) �,/ 1 Q{! t3 (Check Office Below) Verbals Requested Yes No ❑ <br /> ❑ PORTER EJ PLEASANMN ❑ IRVINE ❑ ATLANTA ElOTHER <br /> TEL(219)926.8651 TEL(415)463-9117 TEL(714)757-1755 TEL(404) 951-0055 TEL <br /> FAX(219)926-7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)951-9364 FAX f <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW ❑ OTHER <br /> TEL(303)790-1747 TEL(215)337-2551 TEL(713)$56-1666 TEL(415)960-1640 TEL <br /> FAX(303)799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415)960-0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP • 800 CANONIE DRIVE • PORTER, IN 46304 a TELEPHONE 219 926-8651 • FAX (219 926-7169 <br /> SERIAL NO T?3 6 2 WHITE Field Copy YELLOW PmIW CDR PINI( laboratory Copy <br />