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CANONIE ENVIRONMENTAL GAIN-OF-CUSTODY RECORD 10111 PROJECT <br /> {See Reverse for Instructions) NO <br /> PROJECT NAME(� D1at.� <br /> Ar`.12 r-{�'i�nJV-F—V—Ty SAMPLERS ALV-)< SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (} {PRINTS--' DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER -f -�2�] 04-10 �LjA 40(0 VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BlanklSplke 2 48 Hour <br /> RECORDER G Plastic 500 nit F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SoillSedimeni 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> € AND d d g <br /> ii <br /> qm PRESERVATION m <br /> E <br /> 8 a m mm <br /> SAMPLE <br /> �� <br /> Th <br /> °Q� NOTES ASSIGNED CONDITION <br /> u r 2 2 € a BOTTLE UPON <br /> DATE TIME SAMPLE ID z NUMBERS RECEIPT NOTES <br /> 63259 32Q fA - Z A � b145 A <br /> 0324? t 3Z - <br /> 63259 13 \,.1- q AA--a ✓_ <br /> 7l NAW- I <br /> I -A 31 ✓ <br /> NOTES 1 MISCELLANEOUS _ n E �- Re`np�ug Ished by (Signature) Re elved By](Sign lure) Date Time <br /> 7_ ��.J <br /> `tO U�GN �-Ftt6 A(Z(Z�v{1k�, Relinquished By (Signature) Received (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains OI Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> A2-(�Q Chain (by Serial No} <br /> C-o�21�12- C� L- F40 2 <br /> Send Lab Results 10 (Name) ::GA L�1`f'rECLM �, (Check Office Below) Verbals Requested Yes�A❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OTHER <br /> TEL (404) 9510055 TEL(303) 790 1747 TEL{714} 767-1765 TEL (415) 960 1640 TEL (219) 926 8651 TEL2{ - 9722Z t <br /> FAX (404) 956 9364 FAX(303) 799 0186 FAX (714) 757 0960 FAX (415) 960 0739 FAX (219) 926 7169 FAXZLLc�--f��zS- <br /> ❑ BO7FMAN ❑ 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 A WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 8192 <br />