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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT, <br /> (See Reverse for Instructions) g'�p �3(� q3 p K R NO. <br /> PROJECT NAME QU11J?V C ) HV'Io SAMPLERS) ✓M(�f D � DESCRIPTION CODS A.Q SAMPLE CONTAINER AGsPnd WaterLE FR 00N CODES TAT CODES <br /> PROJECT NUMBER I- C 1 333/(((I' A. Glass LOA veal B. suriaceLeachate <br /> Water a.W walla t. slanders <br /> (SIGN) B. Glass Liter E. Braes Tube C. Leachate 1. tenk/BPlke 2. GB Hour <br /> C. Plastic 5110-m1 F.Other_ D. Rlnaeate L Other_ 3. 24 Hour <br /> RECORDER 0, Plastic Liter E. semsediment G. Other <br /> (SIGN) <br /> NUMBER OF NAL IS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> ': y$ PRESERVATION 8� 88 $€ 3 9` SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> DATE TIME SAMPLE ID r- lit 1jSb139NI3 <br /> 13 <br /> 1,ilyvl -F <br /> Relinquished by:SS!9nature) R ei By: (Sign ure) to Time <br /> NOTES I ^�. /1 MISCELLANEOUS <br /> � `) O •-Z 7 <br /> 'I t3 �uJ�e.JOS 1V15Hic,wiLNA <br /> l+ � q��o Jt� Relinquished By: (Signature) Received By: (Signature) Date Time <br /> Trt��l <br /> 5 tp— <, oc- kip Gil• s <br /> J't— 9saoRelinquished By: (Signature) Received By: (Signature) Date Time <br /> Method of Shipment �Tra/Dn/smp/ortpll ontainer aT Transported with this Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> 0 Chain (by Serial No.) .7 ��/ 103� <br /> Send Lab Results to (Name): N + t (Check Office Below) Verbals Requested: Yes No El <br /> El OTHER <br /> El PORTER ❑ SAN MATED El IRVINE Q��r ElORLANDO <br /> TEL(219)926-8651 TEL(415) 573-8012 TEL(714) 757-1755 TEL(407) 856-7428 TEL <br /> FAX (219)926-7169 FAX (415)573-5654 FAX(714) 757-0960 FAX (407)855-2595 FAX <br /> ElDENVER ElKING OF PRUSSIA ElHOUSTON [-IMT. VIEW ❑ 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 LABORATORY • 212 FRANK WEST CIRCLE, SUITE A - STOCKTON, CA 95206 • TEL.(209) 983-1340 • FAX 209) 983-0304 <br /> SERIAL NO. 01222 WHITE'.Field Copy YELLOW:Protect Copy PINK:Laboratory Copy <br />