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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS &W-01UP112 IREPORT INFORMATION <br /> Client:':—!> A,�► 1 r `Cid Sampler(s): 'Do H Nc7(1 Rush Analysis: 5 Days _2 Days_24hrs_ <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: S Date: Time: QA/QC report required: yea no <br /> Addrresss: 233 UI � �� tf lJ Subject to Surcharge Field Sampler: If yes,To: State_Client _Other <br /> kCAYV( / <br /> 20 i l _A 2_ZZ-G Time image: Lab number. \r�)C3\Q%4 ^Q (-Q 2- <br /> Phone: <br /> Phone: '-1 O'1 - gjI C' - 2O 3 • mumKowl 9 <br /> U <br /> S _ x <br /> FAX: 4aj= MGcov 0 ��� C e 9a Sample Temperature: Celsus <br /> my s o <br /> $ see r <br /> �1,� ()Leaking.()Broken. ( )VOA Headspace <br /> y <br /> Project name: 406 UN.CJ JQS Custody Seal()yes ()no <br /> aA0SAMPLE TRANSPORTATIONContact person <br /> iJi*J <br /> a q x m <br /> mt z s"s '°,° z o <br /> Chest ()UPS ( )Fed Ex ()Drop off ()Other <br /> SAMPLE INFORMATION <br /> ' - ea <br /> Sample Date Time ea <br /> Location Description =0 3 a <br /> Number p Sample Sample � z> w N� �+ S � m <br /> 2 W -4. ANALYSES REQUESTED <br /> 10 0 14.13 - 11D P Del - <br /> Relinquished by: Date(�� ,Time 1' 'Z Received by: Dat&"Time Z <br /> Relinquished by: Date _Time Received by: Date Time <br /> Relinquished by: Date _Time Received by: Date Time <br />