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tANM191 Id1AWbNWN INW-STORY �� JESM <br /> (See Reverse forP <br /> structions) NO <br /> PROJECT NAME .LCA.821.x}_ O7 A2^/^_ SAMPLERS 4LEX 7�o 2i.5 SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES r� <br /> (PRfN DESCRIPTION CODES A Ground Water F oil <br /> PROJECT NUMBER._ _q4Z-3/9 Dz-^10 �il�„c,''7��ft,.l A 40-ml VOA Vial B surface Water G waste 1 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank/Splke 2 48 Hour <br /> RECORDER C Plastic 500-ml F Other D Rinseate I Other 3 24 Hour <br /> (SIGN) D Piastk Liter E SolliSediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY i <br /> CONTAINERS <br /> AND $$ <br /> PRESERVATION $ $'$" ■ ti lL 2 <br /> E 1z E 9 a _ SAM LE f <br /> � — $ . 11 NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE IDy ; ~ . # 1 g BOTTLE UPON <br /> NUMBERS RECEIPT NOTES <br /> 1620 ulv�f- ✓ ✓ I 1 <br /> o -ffin _ ✓ r <br /> a13M Aiw---4r ✓ 1 41 <br /> ✓ <br /> S—Lnn MW ✓ ✓ I ✓ ✓ <br /> 95130 MV4 4, ,/ ✓ <br /> \ I <br /> NOTES l MISCELLANEOUStf <br /> pt.EAS6 Noq; &om PL eltnquy�gd (SI nat e) Received y (Signature Date Time <br /> � �Ra4`[t� �! o til �l lr <br /> AO&LyncA <br /> P elinquished B (Signature) ecel ed By (Signature) D ime <br /> t_ A4 -P4V NL- - <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description Of Other Chains-Of-Custody Dispatched By (Signature) Date Time Zved r lab n;l <br /> Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> ut2t c.G 2 �s'6 S tia..� o�a�q �"`�1 17 qf <br /> Send Lab Results to (Name) -JE-A&1&1 E (Check Office Below) Verbals Requested Yes ❑ No ❑ <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER ICI OTHER <br /> TEL(404)951-0055 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 FAXiM, 56), <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)337-0550 FAX(510)463-2981 FAX(503)241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE (303) 290-8336 • FAX (303) 290-8013 <br /> SERIAL NO A n n ^ r- WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV 5192 <br />