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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME "7 F "r ) ` 'r r}T 1> - SAMPLERS �� t Y ` ' I` ' SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> " -I �-1--1 a (PRINi�Jr 7 t� DESCRIPTION CODES A Groundwater F Oil <br /> PROJECT NUMBER A 40 ml VOA Veal s Surface water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H SlanktSpike 2 48 Hour <br /> RECORDER C Plastic 500 ml F Other D Rmseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E S4drSedlrrmenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> `o AND xr <br /> e ,! PRESERVATION 9 t1 $R = <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> i7i <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID N °7 I I I I I I Z NUMBERS RECEIPT NOTES <br /> �%fiL�+h �.f�?{1 �V 1 .. t1 rr ✓ <br /> 02624 f, W f <br /> o , 1 10 v77 <br /> Y <br /> f' <br /> NOTES!Mi CELLANEOUS r t. i� r el)nqulshed by (Signature) Recpiv y Signature) _ ate Time <br /> 1 T-O u (A A>ti t r I I r r t *�% f ��, L �., -� �C S� z . +� Mile <br /> M l� <br /> I L Relinquished By (Signature) Receiv d By (Signature) Date Time <br /> , <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains 01-Custody Dispatched By (Signature) 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) EANh1E 0M,,E (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER �OTHEA h 10 C STC7 <br /> TEL(404)951-0055 TEL(303)790.1747 TEL(714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL r <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 WRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SM 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • F3) 290-8013 <br /> SERIAL NO 17•1 7 I WHITE Field Copy YELLOW ect Copy PINK Laboratory Copy REV 8192 <br />