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CANONIE ENVIRONMENTAL ' ` `: <br /> CAIN-OF-CUSTODY RECORD <br /> �c�.�QA� <br /> (See Reverse for Instructions) <br /> NO t f <br /> PROJECT NAME t�'jy SAMPLERS Pq.ext-�f 't SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 95-1�y7 T - (PRINT)^�C-"- DESCRIPTION CODES A. Ground'Waier F. Oil <br /> PROJECT NUMBER + -� 12- .+ �` "`'�' f yf-=��-� A_ 40-ml VOA Vial B. Surface Water G. Waste 1. Standard <br /> (SIGN) B. Glass Liter E. Brass.,Tuba ' <br /> Leachate H. BlanklSpike 2. 48 Hour <br /> RECORDER C. Plastic 500.m1 O heF `�i.l(. b9 Rinseate I, Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter s �}R Hyl 1t E. Soil/Sediment <br /> 4- Other' <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS �, , <br /> U <br /> � AND <br /> PRESERVATION <br /> m o d x 2 a E 8 N5 SAMPLE <br /> _ V „ �d v a m o� NOTES ASSIGNED CONDITION- <br /> DATE TIME SAMPLE ID 3 A o BOTTLE UPON a <br /> rj3+ �-� NUMBERS RECEIPT NOTES <br /> A F [/ Y ! r/ t LILj ./ 1.I t tDYt (� ul <br /> S q _1112 0 Cti i vl �- f 3 ,✓ �' �� �' t f zr <br /> t r� <br /> la t <br /> r----------------- <br /> RIvtirj. <br /> t-1-1I L r,.rsC.. <br /> 1 t\4hSL <br /> i <br /> NOTES 1 MISCELLANEOUS Reli <br /> L y y�vyy �J ��'b0 r 4 shed by: (Signature) R By: 1 ature Date Time <br /> 'T v �` AS �l V ` �f.� ,. r;� :t ati <br /> r { LTEh/ Relinquished By: (Signature) Received By: (Signature) 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 lab By: (Signa(ure) Date Time <br /> Transport Container Transported with this <br /> " a Chain (by Serial No.) <br /> (10 U01e ... �rI'.(�;( or�,1' r��.� � .--i,- (7y0 <br /> Send Lab Results to (Name): 11<L r 431{J~1 h (Check Office Below) Verbals Requested. Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTEROTHER �E STU <br /> TEL(404) 951-0055 TEL (303) 790-1747 TEL (714) 757-1755 TEL (415) 960-1640 TEL(219) 926-8651 TEL Lc� <br /> FAX(404) 956-9364 FAX(303) 799-0186 FAX(714) 757-0960 FAX (415) 960-0739 FAX (219) 926-7169 FAX <br /> BOZEMAN <br /> Q 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) 555-0P66 FAX (215) 337-0560 FAX(510)463-2981 FAX(503) 241-0486 FAX <br /> A!' <br /> CANONIE ENVIRONMENTAL SERVICES, CORP •6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX 303 290-8013 <br /> SFflIA�NoG I l r i wrlT Heli copy Yw.ow;P(olecl Copy Mr:Faboraloir copy AF P12 <br />