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AB PROJECT <br /> C%NIE ENVIRONMENTAL*AIN-OF-CUSTODY RECORD <br /> Fr mcz 0, 1 - �r (c ArSPSs , (See Reverse for instructions) NO <br /> PROJECT NAME A SAMPLERS AcrOY1304SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> q (P ) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER ! 1--"` C 3�_ '^ A 40-mi VOA Vial a Surface water G waste Standard <br /> LQ�. (SIGN) B Glass Liter rarss T�u� C Leachate H Blank(Spike 40 Lr <br /> RECORDER -�+ C Plastic SDe-ml her p Rinseete I Other 3 24 Hour <br /> (SIGN) D Plasik filar E 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> $ AND <br /> �— $— PRESERV/STIONSAMPLE <br /> i <br /> d- NOTES ASSIGNED CONDITION <br /> �- BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> ! 15.o <br /> nn C <br /> r V <br /> r SI <br /> 4 � <br /> --L I I I lit <br /> NOTES!MISCELLANEOUS Relinquished by (Signature) R spit 11 _d— Date Time <br /> Relinquished By (Signature) R sive 139 (Sig r ) atij iln`e <br /> I=eltnquished 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) bate Time <br /> Transport Container Transported with this <br /> Chain(by Serial No) ? <br /> � r <br /> Send Lab Results to (Name) _.61fltif ,'D/I (Check Office Below) Verbals Requested Yes (No ❑ <br /> ❑ PORTER 13-KEASANTON ❑ IRVINE d ATLANTA ❑ OTHER <br /> TEL(219)926-8851 TEL (415)463.9117 TEL(714)757-1755 TEL(404)951-0055 t TEL <br /> FAX(219)926-7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)951-9364 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT^VIEW f ❑ OTHER I <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 • PORTER, IN 46304 • TELEPHONE (219) 926-8651 • FAX 219) 926-7169 <br /> SERIAL NO 1 ,116t WHITE Field Copy YELLOW Projed Copy PINK Laboratory Copy <br />