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CANONIE ENVIRONMENTAL' CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO, q-10 <br /> PROJECT NAME SAMPLERS <br /> .9SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> --(PRINT) DESCRIPTION CODES A. Ground water F. oil <br /> PROJECT NUMBER { � j A 40-m1 VOA Vlal B. 5urrace Wates G Waste 1. Slandard <br /> (SIGN) B. Glass Liter E, Brass Tube C. Leachate H. BlanklSplke 2. 49 Hour <br /> RECORDER C. Plastic 5OD-ml F.Other D. Rinseale I. Other 3. 24 Haur <br /> (SIGN) D. Plastic Liter E, Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED <br /> CONTAINERS LABORATORY USE ONLY <br /> o AND c $ <br /> g ag PRESERVATION <br /> T-1- -- <br /> A <br /> � ¢° E B _� SAMPLE <br /> au NOTES ASSIGNED CONDITION <br /> _ m rm m— <br /> DATE TIME SAMPLE ID nVm ~v a BOTTLE UPON <br /> (� y z NUMBERS RECEIPT NOTES <br /> 3 <br /> } <br /> NOTES l MISC LLANEOUS Relinquished by: (Signature) ec a By. S' naWre Date Time <br /> i <br /> Nri I gna e) v }I: Ignature) ime <br /> Re quished By: (Signature) Received By: (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Cuslody Dispatched By: (Signature) DateTime Received for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> NA AA C,S , Chain (by Serial No.) r <br /> ySo � <br /> Send Lab Results to (Name): (Check Office Below) V bats Requested: Yes ❑ No ❑ <br /> F] ATLANTA ❑ DENVER El ❑ MT VIEW ❑ PORTER "HER tir ■ .– cT/] <br /> TEL (404) 951-0055 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 - <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) 397-0560 FAX (510) 463-2981 FAX (503) 241-0486 FAX <br /> CANON—IF R-ti1i.lONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, Si:':,.:: ::300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FA7: 3) 290-8013 <br /> S€RIAL NO. 09 fi T. ',. WHITE:Field Copy YELLOW:'i,4jJc1 Copy PINK:Laboratory Copy '-� REV_0192 <br />