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PRoJecr- <br /> CANONIE ENVIRONMENTAL 1�;IAIN-OF.-CUSTODY REOOR9 : . <br /> (See Reverse for, [nstructlons) ,� _ N0. <br /> PROJECT NAME _ SAMPLERS /�� 0)4� "µ SAMPLE CONTA� NT + 'IAMPLE dESCRIOT16N CG�D55 r TAT CODES: m ' <br /> 01 7 t I T) DE$CRIPTIONy�CIDE$, k aroihd Water �". ion <br /> PROJECT NUMBEFI ` .=:, Ar 44rr�LVOAVIaI L3 eiS 3 i �. Sur{ac$Water �, .aWeate d ..r 1 Standard Y ry rJ <br /> 1 <br /> r <br /> (SIGN) <br /> Y .8 Glene,Lher E_r8fase T C. Leachal6. m H .Btenk)SRlha 2::4a H 1. +L <br /> h. :. <br /> ti.A+ )+' r C:�P16a c SWTI F•OtHe rl �� }. D. RlnaeaEe i Other a- " 3. 24 Hour* cr c� �j <br /> r RECORDER _ h t.. ICr7 e <br /> {61GN) t + F•; 1 J I' 9i •I+ .D 1 Plaatle <br /> Liter'. r,ti E. 9oll?8edlmenl Li rJ f', 4.:Other- <br /> 1.4m <br /> NUMBER OF A LAB <br /> PSIS REQUESTED s'F '- a R 5 �'. ' ORATORY USE ONLY - <br /> k. CONTAINERS <br /> AND <br /> PRESERVATION <br /> d ry GI [i SAMPLE <br /> UPg N01`ES ASSIGNE�S r CONDITION. ' <br /> M.L. rBOTTLE:,, UPON 2s J <br /> DATE TIME SAMPLE ID — ' <br /> 1' $ NUMBERS' s q RECEIPT r NOTES" <br /> DI w �sl <br /> i <br /> J <br /> V1} i <br /> NOTES/MISCELLANEOUS <br /> T Re Iriquishe (5lgnature - e}' " �}}�^Qr'A ��ry+ ( T �+ <br /> + r l r TA <br /> r. <br /> Flelinqu4ehed By'(6gnplure) ; • e eV By: ( Ignatute)`r ale:` .� �rpe <br /> Y t <br /> Relirlqulshed Py (SIen9lure) ' �r ece�ved By: (Si netu(e) Dale. Thile <br /> ,4 • r ii �5, jl s3 •ri liJ I I T; <br /> Method of Shipment Descri i r. <br /> ton of Other Chei s <br /> P ns Of Custtid Dis etched B J: i <br /> P y P y (S gnature} Date .. Tlme r � ecelved for lab By; (Signature) Date r Tlr{�e' <br /> Transport Container Transported'Wilh this i-r , + r �- <br /> r : Y Serlell Na} rr , t r. v : t <br /> P/(t,�I,, of?n C�u,ula�t � �-�� � :►f���'' `' �(�rw-� . .'G{���R�': ��u �E �� <br /> Send-Lab Results to (Name): r, ' <br /> ( )' "` '�'`'�' {C�ieck Offfceltiw) =Verbals Requested; Yes ❑' No <br /> ?; a t $5 gar �. <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE` ❑ MT.yieN °i t 1;O�IT R ',' OTHER <br /> TEL(404) 951-0055 TEL(303) 790-1747 . . TEL (714).757-1755 TEL(415)960-1640 `� ITEL-(219)926-8651 Tat.;, <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX.(714) 757.0960 FAX'-f415)960,07,3,9 N r FAX(219).926-7169 FAX <br /> ❑ BOZEMAN ❑ HOUSTON - d KING OF PRUSSIA ❑ PLEASANTON r, <. L S O rRAND ❑ O1NER <br /> TEL(406)566.9499 TEL(713)556-1666 1 TEL(215)337-2551 . I a TEL(510)463=9117 iTEI�",'{693) 241-0282 I} I. TEL <br /> FAX,(408)566.9724 'r' FAX(713)556-0666 S.' .1 n s;.FAX(215}.33�0560 rFAX($10)4133, 5(91 x5 rs 1= `( t)3) 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. ^ 7 WHITE;Field Copy YELLOW:Project Copy . PINK:Laboratory Copy REV,&02 <br />