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CANONIE ENVIRONMENTAL CHAIN—OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO. <br /> SECT NAME F L O SAMPLERS 12 .6bL SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PR' DESCRIPTION CODES A. around water F, ON <br /> JECT NUMBER I — .1.1141 A. 40-ml VOA Vial�'/ B. Surface Water e. wow 1. Standard <br /> I 1 B. plass Liter Tube C. Leachate H. Blank/Wke E dB Now <br /> C. Plsatlo WO Other 0. Rhaeate L Other 3. HOW <br /> RECORDER D. Plastic Liter IlSedlment 4. otter <br /> {sK�N1 - <br /> NUMBER of ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> r A SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> ITE TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> AK <br /> 1rN -F~'S0 v 5 T- W <br /> %Z <br /> I : IDV S_ P i 1 1 T4­11I1*4! c . <br /> '1, OrS — sP- 2 TR 11 <br /> OTES!-MISCELLANEOUS Rel[ (Signature) Retelved By:(Signature) <br /> s� s� -T� SIJ !4R-r� aFits <br /> 1b , <br /> 3o 36 Relinquished By: (Signature) Received By:(Signature) Time - <br />�1,(� 9AVE CGL Relinquished By:(Signature) 99celved By;(9lgnaturs) Date Time <br /> �----- <br /> Method of Description of Other Chains Dispatched By: (Signature) Date Time Rtbashned M By:(SignatureD Time <br /> Transport Container Transported with this `�� <br /> 1�- U► Chain(by Serial No.) I <br /> CpvLrF-rte <br /> Sent! Lab Results to (Name): (Check Office Below) Verbals RequbMed: Yes ❑ No ❑ <br />❑ PORTER PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <br /> TEL(219)926-8651 TEL(415)463-9117 TEL(714)757-1755 TEL(404)951-0055 TEL <br /> FAX(219)928.7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)951-9364 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT. VIEW ❑ OTHER <br /> TEL(303)791}1747 TEL(215)337-2551 TEL(713)556-1688 TEL(415)980-1640 TEL <br /> FAX(303)799-0186 FAX(215)337-0560 FAX(713)556-0668 FAX(415)960-0739 FAX <br /> GANONIE ENVIRONMENTAL SERVICES CORP. • 800 CANONIE DRIVE + PORTER, IN 46304 • TELEPHONE (219)_926-8651 + FAX 219 926-7169 i <br /> RIAL NO w^ WHITE:Field Copy YELLOW:Prohp OWY PINK:Laboratory Copy <br />