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CANONIE ENVIRONMENTAL MAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse for Instructions) NO g <br /> PROJECT NAME SAMPLERSN�'�1 SC o&4 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �1 {P NT) r DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER —! - 3 3 - 0 T44,. off J Cavo.,- A 40-ml VOA Vial 8 Surface water G waste 1 Standard <br /> (SIGN) 8 Glen Liter E Brass Tube C Leachale H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 5Mml F Other D Rlnseate I other 3 24 Hour <br /> (SIGN) D Plastic Laer E SollfSedrment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> U <br /> AND $ <br /> PRESERVATION Q <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDV t ~ ' = BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> 67111 JEW K I A AA w `'I A A A 3 tJ-1 dw <br /> 01[1111'r 03 oIA AA w A e3 y i <br /> I <br /> NOTES!MISCELLANEOUS Rahn wished b nature R e vsd <br /> q y (iia ) ( ignatur ) Date Time <br /> Rellnqulshe By (Signature) Receive By lgnatu e) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) Date Time Received for tab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> i <br /> Send Lab Results to (Name) I I D 'Yi'4c f (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL tR7-01??P-3rt <br /> FAX(404) 956.9364 FAX(303) 799-0186 FAX(714)757-0960 FAX(415)960-0739 FAX(219)926.7169 FAX -a►`ZZr•3 s-B q <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406)586-9496 TEL(713) 556-1666 TEL(215)337-2551 TEL(510)4639117 TEL(503)241-0282 TEL <br /> FAX(406) 586-9724 FAX (713) 556.0666 FAX(215)337-0560 FAX(510)463-2981 FAX (503)241-0486 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 NQ 15513 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 13192 <br />