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CANONIE ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME 41418 OM SAMPLERS ALEXCtO S SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �,( (PRINT], DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER 7�1 >� A 40-ml VOA Vial B surface water G Waste i Standard <br /> (9113N) B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic 5l) mI F Other D Rmseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E SolliSedomenl 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND �_ e <br /> PRESERVlQION 8� <br /> LL € _ SAMPLE <br /> z `o €F� 69 NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID v § = NUMBERS RECEIPT NOTES <br /> i <br /> 04 •2 AIAI V 1 1/1 <br /> OM? ' <br /> W•3 p r I <br /> 0429"1 17M W v Y <br /> s 12W p6w.5 A P, v 3 ✓ ✓ <br /> 042,39-T 1210 A A ✓ I <br /> I <br /> NOTES I MISCELLANEOUS pt-CN6e 140 <br /> 76-- <br /> atlnquls Slgnature) Received By (Signatur ) Date Time <br /> LAPJ -MP67- 4T-Uaz U Relinquished B (Signature) Received B (Signature) Date Ime <br /> PQ� q Y ( 9 ) Y ( 9 J <br /> AiLGotJ A'4s,Lt LABS, 14 U.4 L... <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of her Chains-Oi-Custody Dispatched By (Signature) Date Tlme Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> G <br /> Chain(by Serial No) <br /> �9C�n�J W LEIS /s ss --/A. . ,1 Q <br /> Send Lab Results to (Name) - j L-4i -eym A i (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER OCHER <br /> TEL(404)951-0055 TEL(303)790-1747 TEL(714)757-1755 TEL(415) 960-1640 TEL(219)926-8651 TEL Z8'YSP1 <br /> FAX(404)956-9364 FAX (303)799-0186 FAX(714)757-0960 FAX (415) 960-0739 FAX (219) 926-7169 FAX ZJq <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 /> CANON14MWIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, IM 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • 03) 290-8013 <br /> SERIAL NO 1 r r— n WHITE Field Copy YELLCIWjod Copy PINK Laboratory Copy 91W REV &92 <br />