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�C�NME�MUffmiEL'071 <br /> "AfSVCD� bib <br /> o. <br /> (See Reverse yr Instructions) NO— <br /> PROJECT NAME ! ` SAMPLERS 1i itr pt^M &" SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> T# DESCRIPTION CODES A Ground Water F Oii <br /> PROJECT NUMB> R_ ��� i Z—A) ] �� � . �y A 40 ml VOA Vial B Surlace Water G Waste 1 Standard <br /> �j� !/� (SIGN) B Glass Uler E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER t' r� /L1 C Plastic 500 ml F Other ❑ Rmseate I Other 3 24 Hour <br /> (SIGN) ❑ Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND $m " <br /> ma �g PAESEFNATION Y ;g z g t 2 <br /> 38 0$ LL� z v5t Sm `� � �� 3 SAMPLE <br /> d °u ' �c E P �'4� NOTES ASSIGNED CONDITION <br /> a€ am Z `e a ov <br /> DATE TIME SAMPLE ID �' IL E BOTTLE UPON <br /> N = NUMBERS RECEIPT NOTES <br /> i 12-',sT` -7 <br /> NOTES l MISCELLANEOUS I qulsh y ( nature) Received y (Sign re) D to Time <br /> 7 L ! r r5/ - L � / o <br /> Relinquished B SI nature F�� Iv 1 Da r me <br /> �tCy (Signature)) oco ed ( Ignature) Date Time <br /> rnVic tr.�f� <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> .�t�r,. ff d4� �''rl t"(�:) .2r�r`�S cfc�C�r4�— lac v5.e �►� ; � <br /> Method of Shipment escnption ofther Chains Of Custody Dispatched By (S(gnature) 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) tN" V-'Q01 (Check Office Below) Verbals Requested Yes ❑ N,,�oJ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE El MT VIEW 11 PORTER f' d-OTHER e3f(,) <br /> TEL (404) 9510055 TEL(303) 790 1747 TEL(714) 757 1755 TEL (415)9601640 TEL (219) 926 8651 TEL 2aL579 LZ2f <br /> FAX (404) 956 9364 FAX (303) 799 0186 FAX (714) 757 0960 FAX (415)960 0739 FAX (219) 926 7169 FAX ? 'Z S <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) 2410466 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, GO 80111 • TELEPHONE (303) 290-8336 • FAX 303) 290-$013 <br /> SERIAL NO 14 <br /> G 9 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />