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"ITI�VV Nlt�T C. MMO MjIU R' �. -G i U U�,u�Revmr <br />PROJECT NAME le � � SAMPLERS 1f �' 4`� `"' <br />(P INT) SAMPLE CONTAINER SAMPLE DESCRIPTION CODES <br />rins,,...,lotia) <br />TAT CODES <br />G <br />�� _ 7 y —� U <br />- L- DESCRIPTION CODES <br />A. Ground Water <br />F Oil <br />O Standard <br />PROJECT NUMBER 'I ,; <br />A: 40-m1 VOA Vial <br />(SIGN). Q <br />B., Glass Liter Brass Tube <br />B. Surface Water <br />C. Leachate <br />G. Waste <br />H. Blank/Spike <br />2. 48 Hour <br />RECORDER .1 ' <br />. <br />C. Plastic 500=m1 .' F. Other <br />Rinse <br />E. SoIVSediment <br />1. Other <br />3. 24 Hour <br />4. Other <br />(S CN) <br />D. Plastic Liter <br />c <br />l <br />a <br />. NUMBER OF. <br />ANALYSIS <br />REQUESTED <br />m <br />Y <br />x <br />LABORATORY USE ONLY <br />a <br />u <br />'$ <br />CONTAINERS <br />c <br />U <br />ANALYTICAL LAB ���u6 / e2 <br />2 <br />v, <br />AND <br />PRESERVATION <br />-' <br />x <br />w <br />« <br />_ d <br />9 <br />d <br />GJECT-N <br />..' <br />o-, <br />_�� <br />960 D <br />2D <br />c <br />a <br />CL <br />v <br />o <br />Q4 <br />d <br />E¢ <br />m" <br />a <br />ASSIGNEDAVERAGE <br />SAMPLE <br />° I <br />u, <br />� <br />NOTES BOTTLE <br />CONDITION <br />TEMP <br />W <br />t�U <br />E°a <br />> <br />NUMBERS <br />UPON <br />RECEIPT <br />NO. DATE <br />TIME SAMPLE ID -F mlcromhoslcm <br />X <br />x <br />2 <br />T_2 <br />.. <br />X <br />-- <br />3 <br />-i- <br />x <br />X <br />3 <br />a <br />2 -,2 -- <br />X • <br />ti <br />5 <br />s <br />3 -?-.. <br />_ <br />x <br />X <br />6 <br />( <br />TN -1 <br />XX <br />8 <br />t� -z - <br />9 <br />XX <br />.X <br />10 <br />- z <br />%( <br />Y <br />. <br />11 <br />D-3- <br />K X <br />X <br />- <br />/ <br />12 <br />yL� <br />X <br />z <br />13 <br />_ <br />t <br />14 <br />15 <br />77�7i�u <br />NOTES/ MISCELLANEOUS Field Container Temp; <br />R he •y ($ Nature) <br />Received By: (Signature) Date <br />Time <br />Relinquished B lgliature) <br />Received By: (Signature) Date <br />Time <br />Relinquished By.�Signature) <br />Received By: (Signature) Date <br />Time <br />Container Sealed with Custody Seal: Yes ❑ No❑ <br />Method of Shipment <br />Description of <br />Other Chains -of -Custody <br />Dispatched By: (Signature) . } Date <br />Time <br />Received for lab By: (Signature) Date <br />Time <br />Transport Container <br />Transported with this <br />Chain (by Serial No.) <br />ev <br />)Oq qo <br />�u� <br />Send Lab Results to (Name): �(r� Gov r/� (Check'Office Below) Verbals Requested: Yes 1 No ❑ <br />SERIAL NO. MOUNTAIN VIEW • 441 NORTH WHISMAN ROAD, BLD. 23 • MTN VIEW,. CA94043 e TEL (415) 960-1640 • FAX (415) 960-0739 8 6 <br />❑ PLEASANTON • 7901 STONERIDGE DRIVE, SUITE 100 • PLEASANTON, 'CA 94588 • TEL (510) 463-9117 • FAX (510) 463-2981 Y <br />20941 ❑ OTHER TEL FAX A <br />WHITE: Field Copy YELLOW: Project Copy PINK: Laboratory Copy REV. 0195 <br />