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CANONIE ENVIRONMENTA*HAIN-OF-CUSTODY RECORD AB PROJECT <br /> (See Reverse for Instructions) 149 - <br /> r�� k _ tc� <br /> PROJECT NAME x ?cc <br /> ,. � SAMPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES ' <br /> � IN DESCRIPTION CODES A Ground water F oil <br /> PROJECT NUMBER J�r r�! � r� IC t' A 4(>mi VOA vial B Surface Water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500�mi F Other 0 Rmseate 1 Other 3 24 Hour <br /> fSION) 0 Plastic Liter E SoNSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> p n PRESERVATION Y_ <br /> 5 4 yF"1 B ES a a �' SAMPLE <br /> 6 ly _ \} �+ i E r~ au u NOTES ASSIGNED CONDITION <br /> f , iV I' a' BOTTLE UPON <br /> DATE TIM SAMPLE ID = NUMBERS RECEIPT NOTES <br /> ;c 1• ( r JIV . <br /> tt`yZnont <br /> 5 r <br /> sf! rte' k 3 i t F r� <br /> •r ' i 1[0 z� <br /> NOTES!MISCELLANEOUS t Relinqufby (Signature) Received By (Signature) Date Time <br /> r, ! <br /> L �� Relinquished By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 'etod a Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> (qo Transport Container Transported with this --� <br /> "`���ttt Cham ( y Serial No} ��WJ ,,L r 0 ?/fir 15 c; <br /> GCS u p.I�� t�0 L�. �. �A � / '� eK/'� (,,1J.7 <br /> Send Lab Results 10 (Name) Ulrf1 �� t,Y A Q (Check Office Below) Verbals Requested Yes A❑nnNo ❑ <br /> ❑ ATLANTA ElDENVER ❑ IRVINE ❑ MT VIEW ElOT <br /> PORTER fl' HER C <br /> TEL (404)951-0055 TEL(303) 790.1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL 1 <br /> -073 7 <br /> FAX (404)956-9364 FAX(303) 799-0186 FAX (714) 757-0960 FAX(415)9609 FAX(219)926-7169 FAX - <br /> .- <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 /> L CANONIE ENVIRONMENTAL SERVICES, CORP • 5300 SOUTH SYRACUSE WAY, SUIT: 300 • ENGLEWOOD, CO 80111 a TELEPHONE 303 290-8336 • FAX 303 290-8013 <br /> SEF AL NO G WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 892 <br />