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B PROJECT <br /> pp / (See Re ve for Instructions) No <br /> PROJECT NAME C 141JIPLER37 <br /> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES <br /> F1 U TAT COPES <br /> Trill V DESCRIPTION CODES A. Ground water F Oe <br /> PROJECT NUMBER " A. 4ml VOA Vial a Burrace water O waste iandu4 <br /> (SIGN) a Alas Leer E Brass T C t.eschata H Blank/Spike <br /> RECORDERLC Plastic 300{nl F Other] O Rlnseat}} L her 24 Hour <br /> (SIGN) D Plntle Lher ]�[.• E BoRlSedlmsnt 4 Mar <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> OONTAtNERS <br /> AL <br /> AND <br /> PRESERVATION 11F�� h <br /> SAMP>E <br /> F NOTES ASSIGNED <br /> BOTTLE UPON CONDITION <br /> DATE TIME SAMPLE ID i NUMBERS RECEIPT NOTES <br /> 176- 1 <br /> NOTES IMISCELLANEOUS gellnq <br /> e by ( gnelure) Received ay (SIA lure Date Time <br /> V0 �= <br /> ed 8y Signature) Re ived H (Si nature) ate Time <br /> Relinquished By(Signature) Received By (Signature) Date Time <br /> r Method of Shipment Description of Other ChalrtW-Cuatody Dispatched Icy (Signature) fate Time Received for lab By (Signature) No_Ie—I Time <br /> Transport Container Transported with this <br /> Chain(by Serial NO) <br /> K + <br /> Send Lab Results to (Name): MA (Check Office Below) Verbals Requested Yesg No ❑ <br /> ❑ POtTf�B}92 8851 TEL <br /> Q IRVINE � „ 0 ATLANTA ❑ OTHER <br /> TEL FAX(219 928-8651 FAX(�483.9117 TEL(714)757-1755 TEL(404)951-0055 TEL <br /> } M 483.2$81 FAX(714)7137-09130 n FAX(404)951-9384 FAX <br /> ❑ DENVER , + ❑ KIN18F PRUSSIA ❑ HOUSTON ❑ MT VIEW ❑ OTHER <br /> TEL(303)M1747 TEL(215)337-Mi TEL(713)558.1888 TEL(415)9ZI640 TEL { <br /> FAX(303)799-0185 FAX(215)337-0580 FAX(713)558-0888 FAX(415)9604739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP. + 800 CANONIE DRIVE • PORTER, IN 46304 • TELEPHONE 219 926-8651 • FAX 219 926-7169 <br /> 6lcRtA1 Na <br /> n Q p i Q WWTE FUSd Copt YFLLWih PrvIM Copy PINK.Laboratory Capt <br />