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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS <br /> r •O • O • <br /> Client: 0 0(�^ S �f���e�r` Sampler(s): t pG C MATION <br /> .�j�(yl��i Rush Analysis: 5 Days _2 Days_24hrs_ <br /> /zo q' �, 7 n ,v Composite Sampler Setup: <br /> Subject to surcharge <br /> Customer Number,..< ) / J r•L( Date: Time: QA/QC report required: yes no <br /> Address: 21 Zd l� W ', l Colk 9*C0Jk Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> LA qS 2041 Time Milage: Lab number: <br /> Phone: AJkV <br /> s - x <br /> � M <br /> FAX: MO�(„�,.L,,,ts �„a"G��u � p� m..; _ Sample Temperature: ZV -t Celsus <br /> c�t�-!. Nor d b x <br /> � a sw � ° z <br /> w ( )Leaking. ( )Broken. ( )VOA Headspace <br /> Project name: S�1 bkf Ea o Custody] yes no Seal( ) <br /> m CH .7 () <br /> ° 3 �Ee <br /> $ v • • <br /> a x <br /> Contact person:��(e°1 v; o d ° <br /> �F z - � .. b z zo 01 <br /> z 33g vs x <br /> SAMPLE <br /> � „�� ( )Ice Chest ( )UPS ( )Fed Ex ( )Drop off ( )Other <br /> • R • • <br /> a <br /> Date Time � <br /> Sample z <br /> Number Location Description o a 3 3 w • A <br /> Sample Sample z> c <br /> 'I <br /> 11 n <br /> Relinquished by: Date VLZ#fime ' S Received by: Date TPA ime <br /> Relinquished by: Date <br /> N _Time Received by: Date Time <br /> o Relinquished by: Date Time Received by: Date Time <br /> N <br /> r\' 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br />