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ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> l }' <br /> (See <br /> {_Reverse for Instructions) NO. <br /> PROJECT NAME V) � '�(` ` O+IIS SAMOLERS� f1v41 Li e;(444h vi SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> C�-��• (PRINT) DESCRIPTION CODES A. Ground water F. oil <br /> PROJECT NUMBER 112— I _ ]�M �� ,�1 --- A. 44rn1 VOA VW B. Surface Water G. Waste 1. Standard <br /> �f ) B. Glass Liter E: Brass Tube C. Leachate H. Blank/Spike 2. 48 Hour <br /> RECORDER . JrD rN V Ci "___ __ _ C. Plastic 500-ml F.Other �_ D. Rinseate I. Other 3, 24 Hour <br /> (SIGN) D. Plastio Liter E. SoillSedimenl 4, Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> m o AND fl Q 8 m a <br /> PRESERVATION 9 <br /> W m <br /> �� $ iL $ ;€¢ ax L SAMPLE <br /> e Pm ao NOTES ASSIGNED CONDITION ` <br /> E BOTTLE UPON s <br /> DATE TIME SAMPLE ID m N _ a7 i NUMBERS RECEIPT NOTES <br /> :,I:' ! o V 1 a Cil ( Rn <br /> `S S f )C V Ve O2� a <br /> C- 5.5 E k kur v3A r <br /> X k V cap, r-- <br /> r <br /> zI t. <br /> NOTES 1 MISCELLANEOUS A l ' �=Z�C eQ ►.! 01- ��} Relinquished by: (Signature) Recei d,By: i 'dt ) Date Time <br /> r f} Jv I�V�S W� RelTh e By ?nature) eceive Si na u e Time <br /> ! I y <br /> P R l e Q;�11o 19- CLT 9 TDC��Q �7o,n o t 4,1, J:i�r. 4z.9 Rei nquis ed j� (Signature) Received By: (Signature) Date Time <br /> 1>D-or- U <br /> Method of Shipment Description Other Chains-Of-Custody Dispatched By: (Signature) Date Time Received for lab By: (Signature) Date Time <br /> Transport Contaiof ner Transported with this <br /> Chain (by Serial No.) <br /> Send Lab Results to (Name): f oJ a (Check Office Below} Ver Is Re uested: Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT ,VIEW ❑ PORTER .``OTHER =�`S <br /> TEL (404) 951-0055 TEL (303) 790-1747 TEL (714) 757-1755 TEL(415) 960-1640 TEL(219) 926-8651 TEL-V 5-79-71 r _ <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 /> CANON IE 11RONMENTAL SERVICES, CORP. • 6300 SOUTH SYRACUSE WAY, S t E 300 • ENGLEWOOD, CO-80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> CSERIAL NO. WHITE:Field Copy YELL ct Copy PINK:Laboratory Copy REV.8192 <br /> T-1711 ;-. - <br />