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CANONIE ENVIRONMENTAL SAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse foTr Instructions) NO <br /> PROJECT NAME Go "f"Lr �� {} SAMPLERS �1�� ��'� 4�" SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES . <br /> n IPRIN DESCRIPTION CODES A Ground Water F oil <br /> D <br /> PROJECT NUMBER k.W ,' A 40 ml VOA Vial B Surlace Water G Waste 1 Standard <br /> ��-•/ (SIGN) B Glass Liler E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER w C P]ashc 500 ml F Other D Rinseale 1 Other 3 24 Hour <br /> (SIGN) ❑ Plastic Luer E 5odlSedimenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS U <br /> c AND `a $ <br /> PRESERVATION x 8 # a o— <br /> . ❑ g aY <br /> LLg g a8 6Y mSAMPLE <br /> BE z e ° �= E o"45 NOTES ASSIGNED CONDITION <br /> e� �` LL �m E o BOTTLE UPON <br /> OA E TIME SAMPLE ID � = NUMBERS RECEIPT NOTES <br /> 31H?Y 11513 -3-1- i <br /> LC5 Cr- Q <br /> �- <br /> tTe -`t3 <br /> I i U-y5 <br /> NOTES 1 MISCELLANEOUS Relinq Ished by ( gnature) Received By (SI nature) Date Time <br /> 'v,3-1;Isp V a <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> �I <br /> Method of Shipment Description of Other Chains Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time lt(� Transport Container Transported with this <br /> Chain (by Serial No) <br /> Send Lab Results to (Name) O ,Y, (Check Office Below) Verbals Requested Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER &0Ji <br /> TEL(404) 951 0055 TEL(303) 790 1747 TEL (714) 757 1755 TEL (415)960 1640 TEL (219) 926 8651 TEL G 519 <br /> FAX (404)956 9364 FAX (303) 799 0186 FAX (714) 757 0960 FAX (415)960 0739 FAX (219) 926 7169 FAX 704 52 <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 NO 1- 4667 <br /> - /I66 `J WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 11192 <br />