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CANONIE ENVIRONMENTAL'' IAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME MCY-TtkJ SSM)Tlf- 64"&L— SAMPLERS ti SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q'L /� (f (PRINT) q DESCRIPTION CODES A. Ground Water F. Oil <br /> PROJECT NUMBER `q—�6'7 01— l n I�R.J �(9,�Qitl A. 40-ml VOA Vial B. Surface Water G. Waste 1. Standard <br /> (SIGN) B. Glass Lifer E. Brass Tube C. Leachate 14. Blank/Spike 2. 48 Hour <br /> RECORDER C. Plastic 500-ml F.Other D_ Rlnsea(e I. Other 3. 24 Hour <br /> (SIGN) D. Plastic Liter E. SolllSedimenl 4. Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> U <br /> 6 g AND d <br /> Pm PRESERVATION �Y m '^ <br /> l+ � S ;E° � SAMPLE <br /> Vz '� y�U Fm E F u NOTES ASSIGNED CONDITION <br /> t = v '` 1 f a C, BOTTLE UPON <br /> DATE TIME SAMPLE IDLr a zNUMBERS RECEIPT NOTES <br /> 6434 laor) 4 M, I I Il ! ✓ <br /> a I310 -21 ✓ ✓ 1 V <br /> D 1325 w- ti ✓ <br /> z r7 M w- v I ✓ r <br /> NOTES�1MIS L �01 *?LEASE RECOP-h SA-mpLc Relinquished y: (Signature) Re ved By: (Signature) s1D Time <br /> e]G Q PA?e- V(�a� Relinquished By: (Signature) Received B (Signature) Date Time <br /> A iLfi1 V p,t� . <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: (Signature) Date Time <br /> ULTKJG- EaC,04-e55 Transport Container Transported with this <br /> Chain (by Serial No.) r� <br /> Lb v ►2 t W O LE+Z <br /> Send Lab Results to (Name): (Check Office Below) Verbals Requested: Yes ❑ No El <br /> ❑ ATLANTA ElDENVER ElIRVINE ❑ MT. VIEW ❑ PORTER LTJ OTHER X400 -STO <br /> TEL(404) 951.0055 TEL(303) 790-1747 TEL(714)757-1755 TEL(415) 960-1640 TEL(219)926-8651 TEL Zoo- <br /> 519-FAX (404) 956-9364 FAX (303) 799-0186 FAX(714)757-0960 FAX(415)960-0739 FAX (219)926-7169 FAX'i0q:jM--Z22.5' <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 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO. Q —J n WHITE:Fleld Copy YELLOW:Project Copy PINK:Laboratory Copy REV W92 <br />