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� rr�r rr ori■ r rr rr r� �r ■r r� !r � rr <br /> CANOIE ENVIRONMENTAL HAIN-OF-CUSTODY RECORD <br /> �„�� LAB PROJECT <br /> S�J9K- (See Reverse for Instructions) NO. <br /> PROJECT NAMEt? SAMPLERS 1 /�I`�D SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> PROJECT NUMBER - 1 (PRINT) -'-' DESCRIPTION CODES A Ground Water F Oil <br /> ,� �fr4 A 40-ml VOA Vial — B Surface Water G Waste <br /> c (SIGN) 6 Glass Liter +rwlra maS b C Leachate H BlanktSplka 2 46 Hour �f <br /> RECORDEh `412A C Plastic 5D4ml F Other D Rlnpep 1 Other 3 24 Flour <br /> (SIGN) D Plastic Liter 4 Other t, <br /> NUMBER of ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION �y,x� Y� � tl <br /> SAMPLE <br /> L � ^`ii� � � � � <br /> Y �€ � NOTES ASSIGNED CONDITION <br /> DATE TIME I SAMPLE ID :Q BOTTLE UPON <br /> NUMBERS I RECEIPT NOTES <br /> .0 <br /> .o I .S <br /> r 7. a v <br /> 1*+y1kxl I0 <br /> h <br /> s ' <br /> NOTES!MISCELLANEOUS 'r P i.K a �/�{{} Q d�U�r , Relinquished by (Signature) 4,06 <br /> r� tare),J ate Time <br /> r-'5'fI" 4-,' Relinquished By (Signature) y=( Ig 1G �} - Date 'Time <br /> �y 11Wice <br /> / /o1 S ,r;Gee & -&4,141&4,14 Ir <br /> PeOUnn�o�t �� ?yS„IF Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) Data Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain(by Serial No) - <br /> 42 <br /> Send Lab Results to (Name) C-Vn O: f 3 (Check Office Below) Verbals Requested Yes fp No ❑ <br /> ❑ PORTER P�PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <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 r <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW ;r { <br /> ❑ OTHER <br /> TEL(303)790-1747 TEL(215)337-2551 TEL(713)556-1666 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 a PORTER,, IN 46304 • TELEPHONE (219) 926-8651 • FAX (219) 926-7169 <br /> SERIAL NO 1 f)11'9 q WHITE Field Copy YELLOW Pro)ec1 Copy PINK Laboratory Copy <br />