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tom,! CAN' CHAIN-OF-CUSTODY <br /> 11Z . ^j <br /> � <br /> CANONIE ENVIRONMENT CHAIN OF CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO <br /> PROJECT NAME SAMPLERS ? fir(ECOA SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> C (PRINT) <br /> DESCRIPTION CODES A Ground Water F OII <br /> PROJECT NUMBER �" _ A 40-m1 VDA Vial ,; � a surface water G waste <br /> (SIGN) a Glass Liter + hC Leachate H 61enklSplke 2 48 Hour <br /> RECORDEh - yt� ��r 0 C Plastic 500-ml F Other D ))Unseats I Other 3 24 Hour <br /> (SIGN) D Plastic Liter 4 Other t <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AND t <br /> PRESERVATION ry 7i <br /> b it <br /> V i <br /> PLE <br /> �" NOTES ASSIGNED CONDITION <br /> DATE TIME SAMPLE ID BOTTLE UPON <br /> . T <br /> NUMBERS RECEIPT NOTES <br /> f4 / X <br /> .0Y Mi <br /> ,D1 �S <br /> .0 <br /> -3 0I, !' <br /> ti <br /> NOTES/MISCELLANEOUS T X A O t�T � 1, Relinquished by (Signature) ReC 1v \ <br /> FOB AQ r'8r�� i ! ( � at're)I J at I fine <br /> Tf7 <br /> Relinquished By (Signature) , pate lime6/GV <br /> 77C' SAn/Wr 1e_ <br /> -- tr i f � Relinquished By (Signature) Received By (Signature) Date Time <br /> Pleatn-lon CA. Sys'% <br /> Method of ShipmenTTC00/P_/ <br /> Description of Other Chains-Of-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> ransporl Container Transported with this <br /> Chain(by Serial No) <br /> r <br /> Send Lab Results to (Name) ,,_,�.' t 3 (Check Office Below) Verbals Requested Yes No El <br /> ❑ PORTER D PLEASANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER <br /> TEL(219) 926.8651 TEL(415)463-9117 TEL(714)757-1755 TEL(404)951-0055 TEL <br /> FAX(219)826-7169 FAX(415)463-2981 FAX(714)757-0960 FAX(404)9519364 FAX <br /> ❑ DENVER ❑ KING OF PRUSSIA ❑ HOUSTON ❑ MT VIEW ❑ OTHER _�r <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)96040739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP a 800 CANONIE DRIVE • PORTM, IN 46304 a TELEPHONE 219 926-8651 a FAX (219) 926-7169 <br /> SERIAL NO 1 ,>? ,gq WHITE Field Copy YELLOW Prosed Copy PINK Laboratory Copy <br />