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AX ,4 ktn'Ft� �QENVIRONMENTAL HAIN-OF-CUSTODY RECORD ��� r k <br /> (See Reverse for Instructions) FSO. <br /> PROJECT NAME S'TKra —' IM A C P-)A(— SAMPLERS 44rx SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> / G�7�F. ®�DZ g - (FRI DESCRIPTION CODES A. Ground water F. Oil <br /> PROJECT NUMBER (9 �tcie_ A. 40-m1 VOA Vial B. Surface water G waste 7. Standard <br /> (SIGN) B. Gla-,s Liter E. Brass Tube C. Leachate H, 81ank/Spike 2. 46 Hour <br /> RECORDER C. Plastic 500-ml F.Other D. Rinseate I. Other 3. 24 Hour <br /> (SIGNt D. Plastic Liter E. SOIIISedirnent 4. Other <br /> NUMBER OF ANALYSIS REQUESTED <br /> CONTAINERS LABORATORY USE ONLY <br /> AND <br /> m nm PRESERVATON $ m n <br /> V �8 ;13 =— oY <br /> LL e mY SAMPLE <br /> t9mgm t ,te <br /> J. <br /> NOTES <br /> ASSIGNED CONDITION <br /> e Z <br /> DATE TIME SAMPLE 10 �mV 5 ~f E o BOTTLE UPON <br /> NNUMBERS RECEIPT NOTES <br /> 040. 10W— 3 2 1 �,, <br /> l�7 ►� <br /> )VI(ml <br /> NATES!MISCELLANEOUS Relinquished by: (Signature) R ceived By: i nat7,411o,11 <br /> Date Time <br /> Lprg : .SEQ 0 01/� <br /> Relirtq (Sl nature) Received By: (Si aiure) Date Time <br /> Relinquis d By: (Si a(ure) Received By: ure) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By: (Signal Date Time Rec ved for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No.) <br /> l6UtJe-tEW- — /Staav A �.,� t-�`.J OY039 /S/F <br /> Send Lab Results to (Name): __1&a-tntnq, (Check Office Below) Verbals Requested: Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTER LZOTHER ti4001esfO <br /> TEL (404) 951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL (415)960-1640 TEL(219) 926-8651 TEI-ZdT--- <br /> FAX (404) 956-9364 FAX(303) 799-0186 FAX(714) 757-0960 FAX (415) 960-0739 FAX (219) 926-7169 FAX <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) 241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, SUITE 3_00 - ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. i r- r n i WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV 8/92 <br /> '�. :". .........-......::.:, . ...�:�:.•• ....:•ti-.:.:res-•-x:....:......... ...-....�r....�-....--.-..��. <br />