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ILM M M M M M Ljww <br /> CANONIE ENVIRONMENTAL IN-OF-CUSTODY RECORD 006 PROJECT <br /> (See Revere for Instructions) NO <br /> PROJECT NAME Aol� ` '� //� SAMPLERS t f` rr SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> v T AINT)�fr � DESCRIPTION CODES A Ground water F Oif <br /> PROJECT NUMBER 1 ~ + - i -/ ,�Jt t ` A 40 m!VOA Vial B Sutlace water G waste 1 Standard <br /> CO �t (SIGN) B 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 Masiic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS u <br /> AND �_ • E <br /> PRESERVATION 2 • aIc <br /> 3 <br /> lz it, gel sU = SAMPLE <br /> • •� <br /> F--Y <br /> $° NOTES ASSIGNED CONDITION <br /> eLL ~ e z NUMBERS RECEIPT NOTES <br /> BOTTLE UPON <br /> ATE TIME SAMPLE ID N 1 <br /> _bIg/ 0 0 <br /> 7 - <br /> NOTES/MISCE� .�NEOUSLIf Ilnc�uis�]�d by { grature) Received By (Slgnatuje) Date Ttme� <br /> ,t ? <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 7 <br /> V 2 N�} CON F'rm 111 010 � <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) `� � r! y�f�� (Check Office Below) Verbals Requers�ted Yes ❑{ No <br /> Fl ATLANTA ❑ DENVER El IRVINE El MT VIEW L1 PORTER LJ OTHER <br /> TEL (404)9510055 TEL (303) 790-1747 TEL(714) 757 1755 TEL(415)960 1640 TEL(219) 926 8651 TEL' r - <br /> FAX(404)956-9364 FAX (303) 799-0186 FAX (714) 757-0960 FAX (415) 960 0739 FAX (219) 926 7169 FAX r � <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 /> CANONIE ENVIRONMENTAL SERVICES, CORP a 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD CO 90111 + TELEPHONE 1303) 290 8336 • FAX (303) 290 8013 <br /> SERIAL NO I ti h 11 WHITE Field Copy YELLOW Project Copy PINK Laboralory Copy REV M2 <br />