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M CAWbMEMd%ENTALSIAff-QFP-&STODfqE&%Dm MOWROW <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME ' (�' i '0 lr r.l SAMPLERS I' t r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground water F Oil <br /> PROJECT NUMBER l f A 40-ml VOA Vial B Surface Water G Waste 1 Standard <br /> (SIGN) 8 Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Plastic SMml F Other D Rinseale I Other 3 24 Hour <br /> (SIGN) D Plastic Liter E Soll/Sediment 4 Other _ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND $_ <br /> r L LL rcs E€ d 1 SAMPLE <br /> e 7033 z 4y,$ �k a �p NOTES ASSIGNED CONDITION <br /> ILL <br /> BOTTLE <br /> DATE TIME SAMPLE ID v 7t ''i ~ NUMBERS RECEOPT NOTES <br /> I Z, } V1 V 5 k/ T-V <br /> /59C7 � li 7 V k1 5 ✓ Y y Y <br /> f il0k , t ,, <br /> ll�rcr Q t'i ' v J v ✓ <br /> 01/2X y !-11 U jV1► I FA V Y <br /> NOTES!MISCELLANEOUSr 1 1 �� 1T I I(�`t_ ell quished b (Signal e) Receiv By (Signature) Date �ime <br /> I L- 4 1 X11' <br /> s ; Relinquished By (Signature) Received By (Signature) D to Time <br /> 17 W- V <br /> 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 Tlme <br /> Transport Container Transported with this <br /> ! t Chain (by Serial No (/�� ,[ O9 Pq9 <br /> 1 e)D L (_ L �'-r II <br /> Send Lab Results to (Name) 0 E � �' ) (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ 113VINE ❑ MT VIEW ❑ PORTER OTHER F aC gIe/,,I <br /> TEL(404)9510055 TEL(303)790-1747 TEL (714) 757-1755 TEL(415)960-1640 TEL(219)926-8651 TEL <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)463-9117 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 /> f _CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 801_1.1 •_TELEPHONE (303) 290-8336 • FAX (303),,.290-6013 <br /> .18635- <br /> SERIAL NO k 8 6 3 5- WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 02 <br />