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CANONIE ENVIRONMENTALSHAIN-OF-CUSTODY RECORD OB PROJECT <br /> lL r� (See Reverse for Instructions) NO <br /> PROJECT NAME _ r,`,U tGAL I SAMPLERS-,6L G: 5 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �,{ (PRIN DESCRIPTION CODES A Ground wale, F OilPROJECT NUMBER �� CI 1 J`� A 40.mt VOA Vial B surface Water G Waste I Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BlanklSpike 2 48 Hour <br /> RECORDER C Plastic 5Mml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soil/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATI N -��,p <br /> 3$ # <br /> x a� u SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDI BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> 4 M - 1bAy ✓ <br /> I X15 A IT <br /> ✓ ✓ <br /> A <br /> r I v ✓ <br /> 1 i 14H MW-5 ) Vol <br /> 0105A I oo MW- <br /> r <br /> NOTES I MISCELLANEOUS FF <br /> �Ir�/Fc. EPa2T d4lnP1Fs Relinquished y (Signature) Received By (Signature) Date Time <br /> LAa: 5o n T�nPE�I-r�� V1%4 �RocelvedBy <br /> Relinquished By (Signature) ture) Dale Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chalns-01Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> �+�otw- C6tJtzt!; 0Lf,9_ <br /> Send Lab Results t 'tZ P. <br /> d (Name) L U T Tic M ttil (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ <br /> ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL(404)9510055 TEL(303) 790-1747 TEL(714)7571755 TEL(415) 960-1640 TEL(219) 926.8651 TEL <br /> FAX(404)956-9364 FAX(303) 799-0186 FAX(714) 757-0960 FAX(415)960-0739 FAX(219)926 7169 FAX2,574 <br /> 2 <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 • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 303 290-8336 a FAX 303 290-8013 <br /> SERIAL NO 7 WHITE Field Copy YELLOW Proier:l Copy PINK Laboratory Copy REV 81+31 <br />