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MCAMbNfMhMOMEffl%L64AW-OF-TUS'MD?WEd%DM M SWROW <br /> (See Reverse for Instructions) NO. <br /> PROJECT NAME _�b1v4'c -S, /�J►'�bn <br /> V-7— <br /> SAMPLERSMAR 13SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> IP I DESCRIPTION CODES A Ground Water f Oil <br /> PROJECT NUMBER A 40-N VGA Vial B Surface Water G Wade 7 Standard <br /> (SIGN) B Glass Liter E Brass Tube C Leachate H Blank(Spike 2 48 Hour <br /> Aa=CORDER <br /> a�aj— t <br /> C Plesik 50Wm1 F Other 4 pinwale I Other 3 24 Hour <br /> (SIGN) D Plaatk Liter E SoWSedlmeni 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND <br /> PRESERVATION $^ u <br /> wi ' <br /> s k SAMPLE <br /> w - < <br /> w� NOTES ASSIGNED CONDITION <br /> �- - BOTTLE UPON <br /> D TE TIMESAMPLE <br /> I D <br /> € <br /> NUMBERS RECEIPT NOTES <br /> z <br /> 1 I <br /> s <br /> �-2-z ,s 1 <br /> - 6, r <br /> 2 rs ! <br /> 13-3-3 S I x I <br /> j LQ3-3- <br /> 6 + r <br /> .sx <br /> c t k I <br /> C • 5 R36 At Lx <br /> NOTES t MISCELLANEOUS Relinquished by (Signature) Received By 5signatu7 <br /> e) Date Time <br /> `0 , <br /> Relinquisbed By (Signature) Recelved By (Signature) Date Time <br /> Relinquished By, (Signature) Received By (Signature) Date Time <br /> , <br /> Method of Shipment Description of Other Chalns-0f-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain (by Serial No) <br /> Send Lab Results to (Name) 14 (Check Officio Below) Verbals Requested Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑,t PORTER ef OTHER <br /> TEL(404)951-0055 TEL(303) 7941747 TEL(714)757-1755 TEL(415)960.1640 TEL{219)926-8651 TEL2—Lj 83$�, <br /> FAX(404)9589364 FAX(303)799-0166 FAX(714)757-0960 FAX(415)960-0739 FAX(219)926.7169 FAX 7 l S3fS�39?g <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER <br /> TEL(406)586-9496 TEL(713) 5581666 TEL(215)337-2551 TEL(510) 463-9117 TEL(503) 241-0282 TEL <br /> FAX(406)5889724 FAX(713)556-0666 FAX(215)337-0560 FAX(510)463.2981 FAX(503)241-0486 FAX <br /> CANONIE ENVIRONMENTAL SERVICES, CORP a 6300 SOUTH SYRACUSE WAY, SUITE 300 a ENGLEWOOD, CO 80111 + TELEPHONE 303 290-8336 a FAX 303 290-80113 <br /> SERIAL NO 15570 WHITE Field Caps YELLOW Project Copy PINK Laboratory Copy REV SM2 <br />