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ATQ, A /k11ES ENVIRONMENTAL&AIN-OF-CUSTODY RECORD OB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME )5�(DkALT SAMPLERS A11X F_(DacS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES w <br /> 6 2-5 9/k UOU) SPRINT) DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER A 40-ml VOA Vial B Surface Water G waste 1 Standard <br /> (SIGN) 6 Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseale I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> U <br /> AND g < m <br /> PRESERVATION $ 88 $ m <br /> E � SAMPLE <br /> >e r �,� <br /> a� NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID <br /> z µ a BOTTLE UPON <br /> ' N z NUMBERS RECEIPT NOTES <br /> 12_pq_U 1.2K w- '01- ✓ v <br /> 122497 As w- <br /> TL It 145 d v <br /> NOTES!MISC!<LLANEOU�Sr PM (q Rehngws� t (Signature) Received By gnature) D e Time <br /> Relinquished By (Signature) I Aecewed_B__y (SigrMura) Date Tlme <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> �oT� 6)-r 7 DD y$ <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) loyM& _ L-ormaffiAm (Check Office Below) Verbals Requested Yes Mo <br /> No Ll <br /> ElElMT VIEW El ATLANTA DENVER IRVINE ❑ PORTER rV` <br /> OTHER oDeS7 <br /> TEL(404)9510055 TEL (303)790-1747 TEL(714)757 1755 TEL(415) 960 1640 TEL (219) 926-8651 TE - <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX(714)757 0960 FAX(415) 960-0739 FAX (219) 926-7169 FA - Z� <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)2410282 TEL <br /> FAX (406) 586-9724 FAX (713) 556-0666 FAX(215)337-0560 FAX (510) 463-2981 FAX(503)2410486 FAX <br /> CCANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENG_LEWOOD, CO 80111 + TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO 14734 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV W2 <br />