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�TO., Ass lNe, ■ ENVIRONMENTAL AIN-OF-CUSTODY RECORD �Ro�E r <br /> See Reverse for Instructions NtS <br /> � 9 ' <br /> PROJECT NAME 24')0EV_T SAMPLERS A LEX 7-10"'L SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (PRINT] DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER 61Z5)_R_(,1_.0_001 ()! )d 11 A 40 ml VOA Vial E Suriace water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H BlanklSpske 2 48 HOOT <br /> RECORDER C Plastic 500 ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soiltse*ment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND g� ` ' m <br /> a <br /> m _g PRESERVATION m— m = a <br /> .AZ A m8 1 � g E r' SAMPLE <br /> +-t" T! ,5 tL �m E ma� NOTES ASSIGNED CONDITION <br /> �v 4` °vBOTTLE UPON <br /> DATE TIME SAMPLE ID � y z NUMBERS RECEIPT NOTES <br /> i <br /> 1 t <br /> U-7 ilkrC <br /> 4a, - L4 A <br /> n v <br /> NOTES!MISCELLANEOUS Reliquis,W.by (Signature) Received By gnture) Date Time <br /> . 1-2107� 1530 <br /> - <br /> 4 <br /> Reit hed y (Signature) R ay (Si ur Date Time <br /> 17/x" <br /> Relinquished 13y (Signature) I Received By (Sign ure) Date Time <br /> Method of Shipment Description ofOther Chains Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this AM <br /> Chain (by Serial No) <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes ❑ No ❑ n <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE I ❑ MT VIEW ❑ PORTER OTHER <br /> TEL(404)951-0055 TEL(303) 790 1747 TEL (714) 757-1755 TEL(415) 960 1640 TEL(219)926 8651 TE <br /> FAX(404) 956-9364 FAX (303) 799 0186 FAX (714) 757-0960 FAX (415)960 0739 FAX (219)926-7169 FA <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-&013 <br /> SERIAL.NO 14733 WHITE Freld Copy YELLOW Project Copy PINK Laboratory Copy REV M2 <br />