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M M M �� 5 ] m <br /> CANONIE ENVIRONMENTAL AIN-OF-CUSTODY RECORD P oJECT <br /> • (See Rev rse for Instructions) NO <br /> PROJECT NAME �+\ SAMPLERS W' �I��` Yt SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> fPRINPfj� �� DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER —I L 11 ` <br /> A 40,ml VOA vial 8 Surface Water G Waste i Standard <br /> ISIGNf B Glass Liter E Brass Tube C Leachate H Blank/Splke 2 48 Hour <br /> RECORDER �� u A, C Plashc 500 m <br /> ! ,�1-�! l F Other D Rmseale I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soitlsediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> c AND $— ? • 8 <br /> wo om PRESERVA110N $ S 9 o_ n <br /> �S kYg a: _ SAMPLE <br /> fie ` z° !`�` a 5FaUaU NOTES ASSIGNED CONDITION <br /> g- " LL �- s E > BOTTLE UPON <br /> TE TIME SAMPLE ID y _ = NUMBERS RECEIPT NOTES <br /> 2 a ] � d d <br /> i� S i + IIH6 Z <br /> e — cf,50 3 <br /> 0W 151f 15 <br /> xo p <br /> 1z-,'5-0 7 — 0 <br /> 13"Y tiY - <br /> - Z4 0 <br /> 25 0 <br /> 0— 15,b 2, <br /> NOTES/MISCELLANEOUS �r iquishgVyy ( nature) Rgcelved By (Signature), Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 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 /> Chain (by Serial No) <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER Ef OTHER M 71' <br /> TEL (404)951-0055 TEL (303) 79D-1747 TEL(714) 757-1755 TEL(415)960.1640 TEL(219)926-6651 TE Zi <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX (714)757-0960 FAX(415)960-0739 FAX(219) 926-7169 F 7 <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 /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290 8336 • FAX (303) 290-8013 <br /> SERIAL.NO WHITE Field Copy YELLOW Prefect Copy PINK Laboratory Copy REV M2 <br />