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0 CANONIE ENVIRONMENTAL *AIN-OF-CUSTODY RECORD 0e PROJECT <br /> 1 ,,lI (See Reverse for Instructions) NO. <br /> PROJECT NAME [ DST C�l NC S 76("6 SAMPLERS A "�X SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 0,_ ag- (PRINT)T DESCRIPTION CODES A Ground Water F all <br /> PROJECT NUMBER l 1- -e4;-s�c.>/ A 40 ml VOA Vial a Surface Water G waste t Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BlanklSplke 2 48 Hour <br /> RECORDER C Plagllc 500 ml F Other D Rlnseale I Other 3 24 Flour <br /> (SIGN) D Plastic Liler E Soil/Sedimenl _ 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> rLi AND FY <br /> IY•J — � PRESERVATION <br /> ySAMPLE <br /> 114: QL- a€ NOTtS ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID �ABOTTLE UPON <br /> v <br />'ih a NUMBERS RECEIPT NOTES <br /> MW- a <br /> Mw - y 1 <br /> o7zg9 <br /> M 14y <br /> MW& 1151 <br /> S ` Zb M u1' 2 ✓ ✓ d I V <br /> - ----------- <br /> NOTES 1 MISCEJ4-ANEOU5 1? Relinquished by (Signature) Receive �alurE le �� e <br /> ILL�� /�t-CAfI 3� 1N�l� R <br /> r 7S <br /> IG-rY�fIC124T(. , Relinquished By (Signature) R ved By (Signature) Date I Tlme <br /> Relinquished By (SlghatUre) Received By (Signature) Dale Time <br /> Method of Shipment Descrrnhon of Other Chains OI-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> L)L7IL^ �X; Transport Container Transported with this <br /> Chain (by Serial No) <br /> Co v 2L,FR-- (!V ae 4 /V,4 <br /> A03 <br /> Send Lab Results to (Name) EA tiPJC flomse (Check Office Below) Verbals Requested Yes ❑ No ❑s <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE Y ❑ MT VIEW ❑ PORTER L7 OTHER <br /> TEL(404)9510055 TEL(303) 7901747 y TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL <br /> FAX(404)956 9364 FAX (303) 799 0186 FAX(714) 757 0960 FAX(415)960-0739 FAX (219)926-7169 FAX Z <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑` PORTLAND ❑ OTHE'h , <br /> TEL(406) 586.9496 TEL(713) 556-1666 TEL(215) 337 2551 TEL(510) 463-9117 TEL (503) 241-0282 TEL "11 <br /> FAX(406) 586 9724 FAX (713) 556-0666 FAX(215) 337-0560 FAX (510)463-2981 FAX(503) 2410486 FAX `4_ <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> I <br />