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L W19 PROJECTCANONIEE ENVIRONMENTAL AIN OF CUSTODY RECORD <br /> (See Reverse for Instructions) N0. <br /> PROJECT NAME ' ' - � SAMPLERS �`tt'� " 'Q SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> 4PRIN DESCRIPTION CODES A Ground water F on <br /> PROJECT NUMBER A 4D-"d VOA VialB Surface Water G Waste 1 Standard <br /> {SIGNi B Glass Liter E Brass Tube C Leachate H Blank/Spike 2 48 Hour <br /> RECORDER C Pisan.5oo-rnt �oC�thll: t D Rinseate I Other 3 24 Hour <br /> (SIGN) D Plastic Liter f E SON/Sediment 4 Other <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> — AND v �, <br /> PRESERVATION <br /> fir _ a SAMPLE 1 <br /> NOTES ASSIGNED CONDITION <br /> BOTTLE UPON <br /> DATE TIME SAMPLE ID CI NUMBERS RECEIPT NOTES <br /> I <br /> of r <br /> 1 <br /> 40ra <br /> fl+ <br /> NOTES I MISCELLANEOUS iiel�nquls�Ig Received BySignature) Date Time <br /> ,�J�yld t3y.{5►gnature} Received By ( t Time <br /> LI� <br /> Relinquished By (Signature) _ Received {Slpnaluie},—^ _ Date Tlme <br /> 2 <br /> *of Shipment Description of Other Chains-Of-Custody DKatchpd By Date Time Rece for 1 B71gr D� Time <br /> ansrt Container Transported with this— Chain (by Serial No) Q `CS <br /> Send Lab Results to (Name) Iwo r r I bv\ (Check Office Below) Verba i Regue d Yes ❑ No <br /> ❑ ATLANTA ❑ DENVER ❑ IRVINE ❑ MT VIEW ❑ PORTER ❑ OTHER <br /> TEL(404) 951-0055 TEL(303)790-1747 TEL (714) 757-1755 TEL(415)960.1640 TEL(219)926-8651 TEL <br /> FAX (404)956-9364 FAX (303) 799-0186 FAX (714) 757 0960 FAX(415)960-0739 FAX(219) 926 7169 FAX <br /> ❑ BOZEMAN ❑ HOUSTON ❑ KING OF PRUSSIA *PPLEASANTON ❑ PORTLAND ❑ OTHER_ <br /> TEL(406) 586-9496 TEL (713) 556-1666 TEL(215)337 2551 TEL(510) 463-9117 TEL(503)2410282 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 1 a 1 7 q WHITE Field Copy YELLOW Project Copy PINK Laboratory Copy REV B/92 <br />