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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for instructions) NO <br /> r A ,f f•-4, rhp� �MA <br /> PROJECT NAME SAMPLERS ) SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (� <br /> ',4 k DESCRIPTION CODES A Ground Water F OilPROJECT NUMBER t 'h` ' '' '� � �'sw _ A 40-ml VOA Vral a Surface water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachale H Blank/Sp eL 2 48 Hour <br /> RECORDER C Plastic Wo-ml F Other D Rlnseate I Other 3 24 Hour <br /> (SIGN) ❑ Plastic Liter E Soll/Seditnent 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND g <br /> _ PRESERVATION $ gm ig <br /> �g <br /> SAMPLE <br /> 6 E€ $ ots NOTES ASSIGNED CONDITION <br /> LL C I� x 1 BOTTLE UPON <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> 06t t - <br /> V <br /> r <br /> Cj <br /> U i t E t-P- I <br /> inub�r <br /> /'5"U u f' (U r �t <br /> IS"rt. j f � 1 } IM J <br /> NOTES 1 MISCELLANEOUS Rehn$1 1�ished by Signature) Rec IV By, (Slg a7W / f Date Time <br /> -U t t�' A , t r U r f) (jv.i_ r"� c trw-�. ��f ` 1 �i <br /> ( Y Relinquished By (Signature) Received By (Signature) Dale Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> I <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 /> Send Lab Results to (Name) a "`"° 7 '¢� / �/ U 6�4• f <br /> (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL(404)9510055 TEL(303) 790.1747 TEL(714) 757-1755 TEL(415)960.1640 TEL(219)926-8651 TEL A^ <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 RONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FA-W31 290- <br /> SERIAL NO � �rl WHITE Field Copy YELL <br /> Copy PINK Laboratory Copy REV 8192 <br />