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EWSet ers lnsMton� DE5 <br /> 1)1 k- 'S7-3 fT SAMPLERS J[rFPCY 0 SA SAMPLE CONTAINER SAMPLE DESCRIPTION CODES <br /> PROJECT NAME r (PRINK �J DESCRIPTION CODES Ground Wale( F Oil <br /> //]] l�i x,6. 40-ml VOA Vial Surface Water G Waste Standard <br /> PROJECT NUMBER-14-2 jp) Iy �U►q�� $ Glass Lder E Brass Tube C Leachale H elank�sp+ke 2 ae Hour <br /> n f�{) (SI N) 3 Oi Hour <br /> 4� f�l'P�^-�-�� C plastic 500-m1 F Other a Rmseale i Other 4 Other <br /> RECORDER D Plastic Liter E So+tlSed[ment <br /> (SIGN) LABORATORY U5E ONLY <br /> NUMBER OF ANALYSIS -I---REQUESTED <br /> CON rAINERS <br /> AND 'u.. < n <br /> d PRESERVATION d u8 Y ��;;_ SAMPLE <br /> Ra Cb mY QU <br /> g$ i "'d NOTES ASSIGNED CONDITION <br /> l r o BOTTLE UPON <br /> 0 <br /> _ _ $ LL NOTES <br /> DATE TIME <br /> SAMPLE ID ya r N z° NUMBERS RECEIPT <br /> i ----------------- <br /> linquished by ignature) Received B (SiWalure) D to Time <br /> NOTES!MISCELLANEOUS <br /> L <br /> i qu h y Signature) Received By ( atur ) Date Time <br /> Relinquis ed (Signature) Received By (Signature a Time <br /> Method at Shipment Description of Other Chains-Of Custody Dispatched By (Sigrglur� Date Time Received for lab By (Signature) Date f Time e� <br /> Transport Container Transported with this �r� e` `' ��5 <br /> r ( �,r` � �k Chain (by Serial l' I f� D �ZLO <br /> L1 <br /> c , <br /> Send Lab Results to (Name) (Check Office Below) V r als Requested Yes El No <br /> ❑ IRVINE ,kms MT VIEW ❑ PORTER ❑ OTHER <br /> ❑ ATLANTA ❑ DENVER \ TEL <br /> TEL (404) 951-0055 TEL(303)790-1747 TEL(714) 757-1755 FAX (415) 960 0739 FAX (219)926 7169 FAX <br /> FAX (404)956 9364 FAX (303)799-0166 FAX (714)757-0960 ❑ OTHER <br /> ElBOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ElPLEASANTON ❑ PORTLAND TEL <br /> TEL(510) 463 9117 TEL(503)2410282 FAX <br /> TEL(406)586 9496 TEL(713) 556-1666 TEL(215) 337 2550 FAX (510) 463 2981 FAX(503) 241-0486 <br /> FAX(406)586-9724 FAX(713) 656-0666 FAX{215) 337-0560 <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 1303] 290 8336 FAX {303) 290 80E3 <br /> 11192 <br /> �! n WHITE Field Copy YELLOW Projecl Copy PINK Laboratory Copy <br /> SERIAL NO <br />