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� ���� CHAIN OF CUSTODY <br /> � <br /> AND ANALYSIS REQUEST DOCUMENT <br /> ■0111 ,11 i ` . ■ . . <br /> i Rush Analysis 5 Days X 2 Days�24hrs <br /> Client 6 L Sampler(5) 0n <br /> Subject to surcharge <br /> Customer Number I <br /> C 11- Comp Sampler Set Up Date __ _ Time QA/QC report required yes no <br /> J <br /> Address gion El Lbi-acJ6 _ __ Time Mileage if yes, To State Client Other r <br /> Lab number Q `�`J ti C) ~0 <br /> Phone <br /> S =y <br /> FAX 3 o <br /> z a 3`�X z O �x <br /> Pl"QJeCt name �, LS ��� r'V/�l/CN !n� �� ©3 <br /> i&_' <br /> C7FQ Q <br /> Contact person 2J5 ��k w <br /> o a � M ar <br /> sF z y> t z o a" <br /> z a <br /> F U u^2SAMPLE TNFORA�N <br /> N i F a`y`�111 C[V! 6i <br /> Sample Date Time Q a m Q <br /> Number Location Description Sample sample �' z° w U <br /> I Diesel /1 '/-C) G C l X x <br /> w0 '-�' L6_ 0 q0 NP > l x X <br /> w ncg a:� -C-z. nJP x X <br /> G) !UP <br /> REMARKSOD <br /> e Relmqu�shed Time / Received by Date 0 O ime Zd <br /> 61 <br /> Relinquished y Date —Time—Received by Date Time <br /> 4 E y� Y DateVU-2— <br /> J <br /> Time 5� C <br /> Relinquished by Date Mime Receroed by Gam , <br /> -r <br /> PRECISION ENVIRO-TECH 7743 N West Lane, Suite B2* Stockton CA 95210*Telephone(209)477-8105*FAX (209)477-8148 <br />