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PREASKIN ENVIR[I=TEEN • CHAIN of CUSTODY <br /> AND ANALYSIS REQ VEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> Rush Analysis 5 Days _2 Days_24hrs <br /> Client � T1_ Sampler(s) o�!S/Pr:S[�� <br /> Subject to surcharge <br /> Customer Number Comp Sampler Set Up Date — Time QA/QC report required yes no <br /> Address 3�d �� �0-6�� Time Mileage If yes,To State Client Other <br /> Lab number 22-913 - 01 - 014— <br /> at <br /> Z923 ` 01 — Q1at sf� <br /> Phone- <br /> FAX <br /> nsC r <br /> Protect name <br /> Contact person Q' � o �, 8 <br /> S- 3 /4Ca 3 La, l z <br /> - —i <br /> SAMPLE INFORMATION <br /> Sample Date Time d a , <br /> Location Description =n <br /> Number p Sample Sample z> a <br /> 6109sel 1/ 36 C7 qC7 Id . aw Z S ndxx <br /> 11 40 a ; 01610 / 3 X <br /> IOWA renu 1/ '56 C74' Lt t2o ' 3 K <br /> MwqI d '�,._ f qC7 NP W 3 JC <br /> REMARKS OD <br /> Relinquished by Da a �r �eceived by DateT�me %30 <br /> Relinquished by Date Tune Received by Date Tune <br /> Relinquished by Date Time Received by Date Time <br /> PRFrTRTnN vvvmn.TFrN 77Aq N Wac+T ana qm+n Rh*q+nnlr+nn P A QF91 n*Talanhnra 19nQ1 A77_Rl ns*PAY (9=A77.R1 dR <br />