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ENVIRONMENTAL SPAIN-OF-CUSTODY RECORD PROJECT <br /> fo <br /> (See Reverse for Instructions) _ _S NO <br /> r <br /> i(f'ROJECT NAME rAl T 11 SAMPLERS A/r�/-f IZ F S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> Q 1 r� /^1 {PRINTL, DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER 62 0 o i 0 nL� A 40-ml VOA Vial B Surface Water G Waste t Standard <br /> " (SIGN) B Glass Liter E Brass Tube C Leachate H BlanldSpike 2 49 Hour <br /> RECORDER �/ ii11 C Plastic SMml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) t` P� D PlasticLder E Soil/Sediment 4 Other <br /> I l <br /> NUMBER OF ANALYSIS REQU T LABORATORY USE ONLY <br /> CONTAINERS U o <br /> wo AND O V`v m a L-I�V <br /> m 5— PRESERVATION it) L O _ if m <br /> +�- 4. S E� � Y SAMPLE <br /> am8m el=$ m`�-` .�3' ASSIGNED CONDITION <br /> ( t e-E z LL 11i r�r c �' s BOTTLE UPON <br /> DATE TIME SAIPLE I 4)% 1 N z NUMBERS RECEIPT NOTES <br /> MO-API , t <br /> ( r <br /> Ad <br /> 7 ' <br /> tZ-zAr e- r <br /> I I <br /> f <br /> xz <br /> , <br /> i <br /> NOTES/MISCELLANEOUS Rellnqu tied by (Signature} 511 Received By (Signature) Date �Time <br /> ; <br /> mfc;;�r <br /> "r F,,A� MTi3E 1 D�P� l ReII quis e y (&g-tiattifej carved By Igna ure) ate Time <br /> EDS <br /> Relinquished By (Signature) Received By (Signature) Date Tlme <br /> S <br /> Method of Shipment Description of I Other Chains Of-Custody Dlspatchq 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) (Check Office Below) Verbals Requested Yes ❑ Na ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE f . ❑ MT VIEW ❑ PORTER EATHER <br /> TEL 404) 9510055 TEL(303) 790 1747 TEL(714) 757 1755 TEL(415)960 1640 TEL (219)926 8651 <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 ❑ PORTLANQ- ❑ 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) 5136 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 /> SERIAL NO 14 7 n 1 WHITE Freld Copy YELLOW Protect Copy PINK Laboratory Copy REV 8192 <br />