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�T A,5 (44S , ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJEC <br /> 1�t (See Reverse for Instructions) NO. .� <br /> PROJECT NAME J<.1 R" eb SAMPLERS 41±-& SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES D <br /> (PRIMA .�7� DESCRIPTION CODES A. Gm.rM water F. Off i <br /> PROJECT NUMBER_ - .� ��T N_LL A. 40 W VOA Vial a. suffice,Wait. e.wean r. Standard t <br /> (SIGN) 9.Oless t.ilor E. Bross lube C. leW w K eaaNfVSpike 2. 4811.., <br /> C. FiWir 500-all F.DOW O_Ripaems I. other_ 24 Hou, F+ <br /> RECORDER i0 <br /> (gam) D. Plks[c lib, E.StllfSetlimanl . ONIar OD <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS _ t' <br /> `dd AND a (11 <br /> a ij- PRESERNRIOH �' � n - (n <br /> SAMPLE <br /> =U NOTES ASSIGNED <br /> CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> l _ ✓ 7 <br /> NOTES MISCELLANEOUS Relinquished by:(Signature) Received By:(Signature) Date Time <br /> LAZ: zbf oc� 2R <br /> Relinquished By: (Signature) Received By:(Signature) Dale TIMID <br /> Relinquished By:(Signature) Received By: (Signature) Date Time <br /> Method of Shipment Deaadplion of Other Chains-Dl-Custody Dispatched By:(Signature) Dale Time Received for lab By:(Signature) Date Time <br /> Transpoll Container Transported wdh this <br /> Chain (by Serial No.) r'- 0 ZGgg <br /> o$� -s t 11 rs <br /> Send Lab Results to (Name): (Check Office Below) Verbals Requested: Yes El No El <br /> ❑ ATLANTA ❑ DENVER El IRVINE ❑ MT. VIEW ❑ POIyG OTRTER HER &Ah&S729 � <br /> TEL(404)951-0055 TEL(363)790-1747 TEL (714)757-1755 TEL(415)960-1640 TEL(219)926-Ml TEL <br /> FAX(404)956-9364 FAX(303) 7990186 FAX (714)757-0960 FAX(415)966-0739 FAX(219)926-7189 FAX 'u D <br /> W <br /> ❑ 13OZEMAN ❑ HOUSTON ❑ MING OF PRUSSIA ❑ PLEASANTON U PORTLAND ❑ OTHER_ <br /> TEL(406)586-9496 TEL(713)556-1666 TEL(215)337-2551 TEL(510)463.9117 TEL (503)241-0282 TEL <br /> FAX(408)58,r9724 FAX (713)556.0666 FAX(215)337-0560 ; FAX(510)463.2981 - FAX(503)241.0486 FAX <br /> CANONIE'04VIRONMENTAL SERVICES, CORP. • 8300 SOUTH SYRACUSE WAY SUITE 300 • ENGLEWOOD OO 80111 • TELEPHONE(303) 290-8336 FAX(303)290.6013 <br /> SERIAL NO. _ 1 C C n n WHITE Fuld Copy YELIOW�P,.y Co. PINK IvM.anm tnrv. -.••--- <br />