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`} PROJECT <br /> CANONIE ENVIRONMENTAL GAIN-OF-CUSTODY RECORD <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME SICK-TOO -2KITIA CAJ+4L- SAMPLERS j4LGK Twee--S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER-944 ^2 01:-10 � A. 40-ml VOA Vial B. Surface Water G. Wasts 1 Standard <br /> (SIGN) 6. Glass Liter E. Brass Tube C. LeAchOle H. Blank/Splke 2. 48 Hour <br /> RECORDER C Plastic 500-ml F.Other D. Rlnseste I. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. Soil/Sediment 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> L . AND $, <br /> — PRESERVATION S� X K <br /> �_ I>tl ¢ € € SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> �� V �V (}t h- VV BOTTLE UPON <br /> 0161655 <br /> E TIME SAMPLE IDV `� �` z NUM6ERS RECEIPT NOTES <br /> >�W- z 2 v <br /> 1105 -'5 A 2 ✓ <br /> W- A V 1 <br /> NOTES 1 MISCELLANEOUS Relinquished by: (Signature) Received y: ( ignature) Da16Time <br /> GFt13� �'+cC,�V�1 14 �p1.�H-5t RECO�'A �w� ►'�� ;�l 1 2S .p ���U <br /> 70 -a j(J(ja vpot j Relinquished By; (Signature) d y: na ure) D to The <br /> Relinquished B (Signature) Received 8 - (Signature) Date Time <br /> 4 Y= ( 9 ) Y' ( 9 ) <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No.) <br /> emot., lZ <br /> NA <br /> Send Lab Results to (Name): /V (Check Office Below) Verbals Requested: Yes 1:1 No ❑,, <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT. VIEW ❑ PORTERCEI/OTHERt0 -15W!i <br /> TEL(404) 951-0055 TEL(303)790-1747 TEL(714) 757.1755 TEL(415) 960.1640 TEL(219)926-8651 TEL I <br /> FAX (404) 956-9364 FAX (303) 799-01186 FAX(714) 757.0960 FAX (415) 960.0739 FAX(219)926.7169 FAXs <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER r <br /> TEL(406) 586-9496 TEL (713) 556-1666 TEL(215) 337-2551 TEL (510) 463-9117 TEL(503) 241-0282 TEL r <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 NO. 18650 WHITE:Field Copy YELLOW:Project Copy PINK:Laboratory Copy REV.8M2 <br />