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i CANONIE ENVIRONMENTAL GAIN-OF-CUSTODY RECORD PROJECT <br /> r 1 (See Reverse for Instructions) NO <br /> PROJECT NAME rMEM6,41V'13 !&M\h C.0 SAMPLERS A _ S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> J� SSP DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER Q 4 -373 -01- 10 �h�C�IL+ ✓ A 40 ml VOA Vial B Surface Water G Waste t Standard <br /> {SIGN) B Glass Liter E Brass Tube C leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rmseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SodlSediment 4 Other <br /> NUMBER OF NALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS u <br /> 4 <br /> AND o $ Q <br /> £5 s <br /> PRESERVATION22 10 m= <br /> 8 � u ;IF o� SAMPLE <br /> $� o a~ m a NOTES ASSIGNED CONDITION <br /> e� 4 = µY �� E °�� BOTTLE UPON <br /> DATE TIME SAMPLE ID1. N z NUMBERS RECEIPT NOTES <br /> W14 r2M vV— K, A i <br /> I <br /> 0 <br /> b � <br /> 2 <br /> NOTES I MISCELLANEOUS elinquishe nature) elve_d By (Signature) Date Time <br /> LAB: A R&CI0 -117 3:.�0 <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 /> -A� ` + Transport Container Transported with this <br /> 0Nqq Chain (by Serial No) <br /> U&,69. <br /> Send Lab Results to (Name) EANIJ (Check Office Below) Verbals Requested Yes ❑ No ❑may] <br /> El ATLANTA El DENVER El IRVINE El MT VIEW 1:1 PORTER OTHER 7Co <br /> TEL(404) 951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415) 960-1640 TEL(219) 926-8651 TE L--Z— <br /> FAX(404) 956.9364 FAX(303)799-0186 FAX(714) 757-0960 FAX(415)960 0739 FAX (219) 926 7169 FAX <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 • FAX (303) 290-8013 <br /> SERIAL NOWHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV W92 <br /> s <br />