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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> n/ (See Reverse for Instructions) NO. <br /> PROJECT NAME l�fb4l]� Q ��APr✓RT11 SAMPLERS At-5) r `S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �! rr �.�1 (PRINT) DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER `�t ` 3rL t7 _ /' LF--1 �v A 40-ml VOA Vial B surface water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other O Rlnseate I Other 3 24 Hour <br /> (SIGN) D Plasllc Liter E SoiVSedlment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS Y <br /> AND _ • <br /> PRESERVATION, <br /> SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE IDV _ x NUMBERS RECEIPT NOTES <br /> rang 0 -2 A x 14 bow v <br /> 2 AA I ✓ <br /> 12,N% 1Q25 KAW—LA <br /> NOTES 1 MISCELLANEOUS RehngtpbAd by (Signature) d B Si nal fD to Time <br /> ( � z 1 . <br /> 'ter1 ) '�R��1� a is y (S nature) 2acelved <br /> e y ( 4�natur ) to Tim <br /> 1ZL4 <br /> Relinquished By (Signature) By ( gnature D to Tlme <br /> i <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 /> pp Chain (by Serial No) <br /> Send Lab Results to (Name) TmA LALMU&htsf (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER ..ER tjyI,4L0-j III <br /> TEL(404)951-0055 TEL(303)790.1747 TEL(714)757-1755 TEL(415)960-1640 TEL(219) 926-8651 TEL M7 <br /> 7122Z1 <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)4639117 TEL(503) 241-0282 TEL <br /> ' FAX(406)586-9724 FAX(713) 556-0666 FAX(215)337-0560 FAX(510)463-2981 FAX (503)241-0486 FAX <br /> CANONIE ALRONMENTAL SERVICES, COMP a 6300 SOUTH SYRACUSE WAY, S 300 a ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • F -311 290-8013 <br /> SrRIAL NO 1,9—,71 ,) <br /> t 717 WHITE Field Copy YELLOVIIIIIIIIIII11d Copy PINK Laboratory Copy IW REV BM2 <br />