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• CANONIE ENVIRONMENTAL SAIN-OF-CUSTODY RECORD PROJECT <br /> (See Reverse foMnstructfons <br /> ) NO <br /> PROJECT NAME/ 4 1.2 ?r f, ;-1 f!1 SAMPLERS " u � ,�L � SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (A INTI DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER _ r f :L i%/ A 40 rnl VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) B Glass Luer E Brass Tube C Leachale H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500 nil F Other D Rmseale I Other 3 24 Hour <br /> (SIGN) D Plast+c Liter _ E SoillSedimenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> o AND <br /> wS oVm PRESERVATION E m— a m n <br /> u yS T. - <br /> _ � mSAMPLE <br /> ao amo`' < "o" NOTES ASSIGNED CONDITIONE" u f E 0BOTTLE UPON <br /> DATE TIME SAMPLE ID N Z NUMBERS RECEIPT NOTES <br /> 2 rl � li <br /> 6.3251 t$Nxl— Ll <br /> U rc r— t<� ✓ r7i� MI) ,/ <br /> yt r1 ✓ �� <br /> NOTES!MISCELLANEOUS Relinquished by (Signature) Received By (Sign ture) Date Time <br /> i .J41T '� 7 y - �Ffvot�_n �gn�I aF'I F IIF+vt�'�V( ���Y� �'Lv ,_ l_ ` ) r 1(^ <br /> ( y �!(�(L�\f (, Relinquished By (Signature) �eceived By (Signature} Date Time <br /> I <br /> j 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 lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> f\V-61()�S Chain (by Serial No) <br /> Send Lab Results to (Name) (Check Otflce Below) Verbals Requested Yes ❑ Na ❑ <br /> EJATLANTA ElDENVER ❑ IRVINE ElMT VIEW ❑ PORTER ID OTHER ALj()j)C_.Sj-( I <br /> TEL (404) 9510055 TEL(303) 790 1747 TEL (714) 757 1755 TEL (415) 960 1640 TEL (219) 926 8651 TEL21:.t_Z-Q,7o-? <br /> FAX (404) 956 9364 FAX (303) 799 0186 FAX (714) 757 0960 FAX (415)960 0739 FAX (219) 926 7169 FAXZCir'i-4:T -; i 1 <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 o FAX (510) 463 2981 FAX (503) 241 0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE t303) 290 8336 • FAX (303) 290 6013 <br /> SERIAL NO4 } , WRITE Field Copy YELLOW Pml—I Copy PINK( ahoralory Copy REV 8192 <br />