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CANONIE ENVIRONMENTALOHAIN-OF-CUSTODY RECORD tB PROJECT <br /> (See Ryerse for Instructions) NO <br /> PROJECT NAME XVY'0) r '"" — SAMPLERS f �'r u4,y t'AA SAMPLE CONTAINER SAMPLE DESCRIPTION COD=S TAT CODES <br /> 9 t f 3 3 3 Q) Try�c uN ��� � DESCRIPTION CODES A Ground water F at <br /> PROJECT NUMBER I NTy A 40-ml VOA Vial B Surface Water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Biank7Spike 2 48 Hour <br /> RECORDER C Plastic 6Mm1 F Other D Rinseate i Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Sail/Sediment 4 Other <br /> NUMBER OF ANALI(SIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND $ • <br /> lb— <br /> — _ <br /> G-gg- — PRESERVATION <br /> a s SAMPLE <br /> d fsNOTES ASSIGNED CONDITION <br /> �� BOTTLE UPON <br /> DATE TIME SAMPLE ID = NUMBERS RECEIPT NOTES <br /> OF 1 \ /11 y <br /> (" r i`t'r 1,flo KIA An tw J <br /> NOTES/MISCELLANEOUS Relinquished by� 4ftnature) Received By (Signature) pate Time vV l <br /> Rellnqulshe By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-01-Custody Dispatched By (Signature) Date Time Received for fab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> Send Lab Results to (Name) to b TM cw- F <br /> (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER 1 <br /> TEL(404) 9510055 r TEL(303)790-1747 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 r <br /> ❑ BOZEMAN ❑ 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)241-0282 TEL <br /> FAX (406) 586.9724 FAX(713) 556-0666 FAX (215)337-0560 FAX(510) 463.2981 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 /> SERIAL NO C •1; WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8M2 <br />