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T7!!3770 <br /> CANONIE ENVIRONMENTAL AIN-OF-CUSTODY RECORD Lae PROJECT <br /> ee / (See Revs for Instructions) ` NO <br /> PROJECT NAME C 14MPLERS SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground wale F Od <br /> PROJECT NUMBERA 40-nit VOA wal B Solace wain G waste <br /> r (SIGN) a Glaas Liter E Brae T C Leadme H aie wsplke <br /> RECORDER C Plastic 500 ml F Omer p ptrgea! 124 NOW <br /> (sly D Plastic Liter E SoWSe�ment �+ • DOW <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS <br /> AM <br /> aa a pftmE%iYArION <br /> SAMPLE <br /> NOTES ASSIGNED <br /> UPON CONDITION <br /> BO <br /> DATE TIME SAMPLE ID NUMBERS RECEIPT NOTES if—i <br /> C <br /> I <br /> 1V x <br /> ti <br /> NOTES I MISCELLANEO Sr I b ( gnature) Received By, (Sig rs uDate Time <br /> r <br /> �LA 10 <br /> eiinq is ed By Signature) R jved B (Si(finature) Date Time <br /> 111 Relinquished Sy (Signature) Received By (Signature) Date Time <br /> I Method of Shipment Description of Other Chains01-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Container Transported with this <br /> V td1 Chain(by Serial No) <br /> Irl D � <br /> Send Lab Results to (Name). � (Check Office Below) Verbals Requested Yes No El <br /> ❑ PORTER PLEASANTON Q IRVINE a Q ATLANTA ❑ OTHER <br /> TEL(219)929.8651 TEL(AA 463.9117 TEL(714)757-1755 TEL(404)951-0055 TEL <br /> FAX(219)928-7169 FAX MR 483.2981 FAX(714)757-0960 ra FAX(404)96141384 FAX � <br /> ❑ DENVER , + Q WAS PRUSSIA ❑ HOUSigN ❑ MT VIEW ❑ OTHER � <br /> TEL(303)790.1747 TEL(215)337-2551 TEL(713)656-1668 TEL(415)9601640 TEL <br /> FAX(303)700185 FAX(215)337-0580 FAX(713)556-0666 FAX(415)9804739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP • 800 CANONIE DRIVE • PORTER, IN 46304 • TELEPHONE 219 926.6651 • FAX 2119 926-7169 <br /> SERIAL Na Fuld Copy WHIM FCopy YFLLWIF PF*4 Copp —PINK LaeaMwy Copy -- -- <br />