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J t _ CANON'-1E ENEN <br /> VIRONMTT <br /> A HAIN-OF-CUSTODY RECORD SAB PROJECT <br /> -TIM 5,.� AsyPSS (]See Reverse for Instructions) NO. <br /> PROJECT NAME '� C // <br /> SAMPLERS ,f` <br /> SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES � <br /> (PRl DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER /— 3 -" S X 40-m1 VOA Vial B Surtace water G Waste -i §jandard i 4 <br /> --(SIGN) B Glass Liter E�T C Leachata H Blank/Spike 2 44 Hour <br /> RECORDER G C Plastic 500-ml F Other D Rinseate I other 3 24 Hour <br /> (SIGN) D Plastic Lher ^ ? 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND yA <br /> — PA SER%WION�� _ •! � V— SAMPLE <br /> � — f'I NOTES ASSIGNED CONDITION <br /> `i! BOTTLE UPON <br /> DATE TIME SAMPLE ID ~ NUMBERS RECEIPT NOTES <br /> 0 ) I <br /> .Olo 1% 5 k <br /> tb <br /> I <br /> f <br /> —7— <br /> NOTES <br /> --NOTES!MISCELLANEOUS Relinquished by !9 re) 8cel p a re 6� in� <br /> I <br /> RelinquishedBy (Signature) Fie eive ay (Sig t r ) D to Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> Method of Shipment Description of Other Chains-Of-Custody Dispatched By (Signature) Dale Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> Chain(by Serial NG) ` <br /> 3 0- <br /> Send <br /> Send Lab Results to (Name) nck ©�f r3 (Check Office Below) Verbals Requested Yes No ❑ <br /> ❑ PORTER EJ'PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER i <br /> TEL(219)92&8651 TEL(415)463-9117 TEL(714)757-1755 TEL(404)951-0055 TEL <br /> FAX (219)926-7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)9519364 FAX ► <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW ❑ OTHER <br /> TEL(303) 790.1747 TEL(215)337-2551 TEL(713)556.1666 TEL(415)960-1640 TEL <br /> FAX(303)799-0186 FAX(215)337-0560 FAX(713)556-0666 FAX(415)960-0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP • 800 CANONIE DRIVE a PORTER, IN 46304 a TELEPHONE 219 926-8651 • FAX (219) 926-7169 <br /> SERIAL NO 12,362 WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy <br />