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CANONIE ENVIRONMENTAL MAIN-OF-CUSTODY RECORD & PROJECT= <br /> • (See Reverse flo nstructions) NO <br /> PROJECT NAME ���7i'%�" �t Z �r17� SAMPLERS 11 f f r f I' _~' SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES ' <br /> (PRINT) 'f DESCRIPTION CODES A Ground Wolof F ou <br /> JB Surface water G waste t Standard <br /> _/, � <br /> PROJECT NUMBER <br /> (SIGN) B Glass Liter E Breas Tube C Leachate H Biank/splke 2 48 Flour <br /> RECORDED C PlasticSWmi F Olher D R,nseale 1 Olhor 9 24 Hour <br /> (SIGN) D Plastic tiler _ E Solpsedlmenl 4 Other <br /> NUMBER OF INALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND n • f g1 <br /> PRE5E ATION a"" <br /> ga " SAMPLE <br /> 11,5111 <br /> 0 k "� " i NOTES ASSIGNED CONDITION <br /> $� Zy°r BOTTLE UPON <br /> DATE TIME SAMPLE ID 1' v § �4 1 g NUMBERS RECEIPT NOTES <br /> V <br /> b A tl I <br /> i <br /> I <br /> NOTES/MISCELLANEOUSCr� Afr! Relinquabad by (Signature) VVcoived By (Signature) Date Time <br /> L_ <br /> Jt: (, K�I A 51 '17�1J'1 Ar(. -vb f4,Lalj Cf 1,%i5& <br /> T Relinquished 8y (Signature) Receiv6 By (Signa!ure Date Time <br /> Relinquished By (Signature) Rec ed By (Signature) Llate T073 <br /> Method of Shipment Description of Other Chains Of Custody Dispatched y (Signature) Date Time Received for 1 By Signature) Date Time <br /> f) n Transport Container Transported with this /6 17,L ro <br /> J C.� &V l (z-- Chain (by Serial No) Sr/ I IPI �� g 0 <br /> p 4T <br /> Send Lab Results to (Name) 1 A A)IQ6 0d (Check Office Below) Verbals Requested Yes ❑ IVa ❑ <br /> El ATLANTA El DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER LJ OTHER /itobe LT` <br /> TEL(404) 9510055 TEL(303) 790-1747 TEL(714) 757 1755 TEL(415)960-1640 TEL(219)926 8651 TE-I._ <br /> FAX(404)956-9364 FAX (303)799 0186 FAX(714) 757 0960 FAX (415)960 0739 FAX(219)926 7169 FAXI <br /> ❑ 807EMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL (406)586 9496 TEL (713) 556 1666 TEL(215)337-2551 TEL(510)463-9117 TEL(503)2410282 TEL <br /> FAX(406) 586 9724 FAX (713)556 0666 FAX(215)337-0560 FAX (510)4632981 FAX(503) 2410486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 303) 290-8336 • FAX (303) 290-8013 <br /> PINK Laboralor Capy REV tugz <br /> SERIAL 140 '7 O WHITE Field Copy YELLOW Project Copy Y <br />