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/CANONIE ENVIRONMENTAL MAIN-OF-CUSTODY RECORD 0 PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME llE�l-'T�� SAMPLERS 'A(-C-x �CUI�t S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES - <br /> f II '4PRINTj�' DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER lot 5Z1 0 0 l ?���'T ��� A 40 ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGNI H Glass Liter E Brass Tube C Leachate H BlanklSptke 2 48 Hour <br /> RECORDER G Plastic 5oo-ml F Other 6 Rinseate i Other 3 24 Hour <br /> (SIGN) D Plastic i{ E SoiUSedrmen[ 4 Other <br /> NUMBER OF ANALYSIS REQUMTE=D LABORATORY USE ONLY <br /> CONTAINERS 1 .� o <br /> a PRESERVATION $ IU 7 m <br /> mY } , r BY 9x <br /> A TU � : gm 'E€ 4�=t SAMPLE <br /> maS x - Im°`� NOTES ASSIGNED CONDITION <br /> LL� to �� 126. �" 2 f E BOTTLE UPON <br /> DATE TIME SAMPLE I � N NUMBERS RECEIPT NOTES <br /> N &m <br /> IDYTO 12,10 NA - H Al3 I <br /> quo �2 <br /> 1007 12.O A <br /> WO"Vtl IC�ZS �W' Z :sKt►AMF Z L <br /> I <br /> 1NOTES IiiMISCELLANE US --(70� `t�+ � I Relinquished by (Signature) Received By (Signature) Date Time <br /> 'b1Q I <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Q� Relinquished By (Signature) Received By (Signature) Date Time <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 /> Cham (by Serial No) 10J '/ �) / w+ 11/ `� �rj <br /> Send Lab Results to (Name) UtA L01TE_R-M1\ (Check Office Below) Verbals Requests Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER "()D�STC) <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960-1640 TEL (219) 926-8651 TEL <br /> FAX (404)956-9364 FAX(303) 799 0186 FAX(714) 757-0960 FAX(415)960 0739 FAX(219) 926 7169 FAX c� 2z7 <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)2410486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SEhtAL NO 1 R 7 2 q WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />