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CA�b�!!�'E�RditE�AI*IAV-0M-UMD�E�C� r• PROPT <br /> f (See Reverse for Instructions) <br /> N <br /> PROJECT NAME d - - �77 SAMPLERS WI I�,,_ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> (Pfil DESCRIPTION CODES A Ground Water F ON <br /> PROJECT NUMBER A 44-rn1 VOA Vial B Surface water G Waste I Standard <br /> (SIGN) a Owe Liter E Brew tube C Leachate H BtanWSplka 2 48 Hour <br /> C Plastic 5MrnI F other D Rinseale I Other 3 24 Hour <br /> RECORDER O PI )c 1.11er E Sd119edimenl 4 Other <br /> (SIGN) <br /> NUMBER OF ANALYSIS RPQUESTED LABORATORY USE ONLY <br /> CONTAINERS Y <br /> AND � ; <br /> PRESERVATION <br /> � _ � SAMPLE <br /> NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE IDT g NUMBERS RECEIPT NOTES <br /> ~z ( I <br /> C �s <br /> G <br /> r <br /> —7r. <br /> � 5 k <br /> 6.5 <br /> �wt <br /> NOTES I MISCELLANEOUS Reil Ws d by Igna e) Re slued By (Sign tura) Date Time <br /> ON Relinquished By (Signature) Received By (Signature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of Custody Dispatched By (Signature) Date Time l Received for tab By (Signature) Date Time <br /> Transporl Container Transported with this <br /> Chain (by Serial No) <br /> 4 , <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes ❑ No Com` <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTEROTHER <br /> TEL(404)951-0055 TEL(303) 790-1747 TEL(714) 757-1755 TEL(415)960.1640 TEL(219)92"651 TEL <br /> FAX(404)956-9364 FAX(303)799-0186 FAX(714)757-0960 FAX(415)96040739 FAX(219) 926-7169 FAX ' <br /> ❑ BOZEMAN Cl HOUSTON ❑ KING OF PRUSSIA ❑ PLEASANTON ❑ PORTLAND ❑ OTHER 1 <br /> TEL(406)566-9496 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 /> CANONIE ENVIRONMENTAL SERVICES, CORP • 6300 SOUTH SYRACUSE WAY, SUITE 300 • ENGLEWOOD, CO 80111 • TELEPHONE 303 290-8336 • FAX 303 290-8013 <br /> SERIAL NO: 15571 WHITE field Copy YELLOW ProOd copy PINK Laboratory Copy REV SM2 <br />