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ti��>� ti� tib �M � ll• � E.—.._.r li � ! � � ri ti �bra �� <br /> CANONIE ENVIRONMENTAL4HAIWOF CUSTODY RECORD LAB PROJECT <br /> Tr^ (l-z Of 1 ' Sr-1 c Ar!�P5,, , (See Reverse for Instructions) NO <br /> PROJECT NAME r A C SAMPLERS t' SAMPLE CONTAINER. SAMPLE DESCRIPTION CODES TAT CODES <br /> {P DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER 'T`�'� A 40-ml VOA"at B Surface water G waste standard <br /> (SIGN) B Glass Liter Fr�tra�e9 Tubo C Leachate H BlankfSpike 4e 6r <br /> RECORDER C Plastic 5Mml F 01her D Flirmate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION , <br /> a SAMPLE <br /> r c€ MOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDBOTTLE UPON <br /> Y g NUMBERS RECEIPT NOTES <br /> r7 <br /> w <br /> If (7 <br /> hI f <br /> ? ry <br /> Sf n <br /> r. r <br /> i <br /> NOTES!MISCELLANEOUS Relinquished by (Signature) Receitfe Ip ati7 ) f Date Time <br /> Relinquished By (Signature) " R eive y (516 r ) atij f Thi <br /> r <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chalns-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 /> 07ie- ]A <br /> Send Lab Results to (Name) CL f �so/I (Check <br /> yOffice Below) Verbais Requested Yes O'No ❑ <br /> ❑ PORTER 13'IPLEASANTON ❑ IRVINE LJ ATLANTA ❑ OTHER <br /> TEL(219) 926-8651 TEL(415) 463.9117 TEL(714) 757-1755 TEL 1404)951-0055r TEL <br /> FAX(219)926.7169 FAX(415) 463-2981 FAX(714)757-0960 FAX (404)951-9364 FAX <br /> Q UF-w a ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT,VIEW f ❑ 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 a 800 CANONIE DRIVE • PORTER, IN 46304 • TELEPHONE (219) 926-8651 • FAX 219) 926-7169 <br /> SERIAL NO 1 n 9 6 t WHtTE Field Copy YELLOW Prosed Copy PINK Laboratory Copy <br />