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• CANONIE ENVIRONMENTAL AIN-OF-CUSTODY RECORD QB PROJECT <br /> 2 (See Reverse for Instructions) NO <br /> PROJECT NAME f K r `S�f}TID.tI SAMPLERS 4Le-x SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> %y�3 w (PRINT) �,� DESCRIPTION CODES A Ground Water F 041 <br /> PROJECT NUMBER 6- �� � -L� 40 ml VOA vial B Surface Water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BlanklSpike 2 48 Hour <br /> RECORDER C Piashc 500 nil F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liler E Soil/Sediment _ 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND a ' <br /> e m m <br /> a m ng PRESERVATION <br /> SAMPLE <br /> ` E � i �� to ¢@ s d°<� NOTES ASSIGNED CONDITION <br /> ES E- n W E °v BOTTLE UPON <br /> DATE TIME SAMPLE ID N z NUMBERS RECEIPT NOTES <br /> No 0- A A 21 13 1 14 ✓ <br /> SSD M W—NMI t ✓✓ <br /> t0 W- <br /> 40 Z - ✓ <br /> 6 - <br /> I <br /> I <br /> NOTES I MISCELLANEOUS ehnquis yatur ) Received.B (Signature) Date Time <br /> SCQ <br /> LA-6. 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 fab By (Signature) Date Time <br /> Y Transport Container Transported with this <br /> Chain (by Serial No) <br /> C' aj�L��. <br /> Send Lab Results to (Name) due (Check Office Below) Verbals Requested Y�eS ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER AMe�0 <br /> TEL(404)9510055 TEL (303) 790 1747 TEL(714) 757-1755 TEL(415)960 1640 TEL(219)926 8651 TEL ?1, <br /> FAX (404)956 9364 FAX (303) 799 0186 FAX(714) 757-0960 FAX(415) 960-0739 FAX (219) 926 7169 FAX-ZU9OZZ <br /> Q U07-E11AAN ❑ 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 NO t N r' !I WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />