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w w w �� �� aw■ �� �� � �� �� w� �� � � �� awe �w <br /> PRE50N ENV1RO-TECH <br /> CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> : .CLIENT DETAILS RFPORT INFORMATION <br /> Rush Analysis 5 Days _ 2 Days_24hrs <br /> Client �` f r1 Sampler s) s I]t a, �s ( r��' C��.,�t�"+�' <br /> j Subject to surcharge <br /> Customer Number \� QA/QC report required yes no <br /> Comp Sampler Set Up Date Time <br /> Address f �� � '� C�C�f �I Time Mileage If yes, To State Client Other <br /> Lab number fie � S U �7 ��� '�--..0 <br />� Phone <br /> -�) r � Iw E <br /> �GGx V <br /> FAX <br /> Project name <br /> z <br /> Contact person F z z o <br /> GO <br /> SAMPLE INFORMATION <br /> O <br /> SampleDate Time <br /> Number Location Description 1 Sample z o a 3 �' w ti U <br /> 1'K f1 1.i f� �{f It !f'u '{ <br /> E 1 <br /> ' E ' e 1 <br /> r__D eceived b - Datdu 6iime <br /> Relinquished pIy Y — <br /> Relinquished byL Date Time Received by Date Time <br /> Relinquished by Date —Time—Received by Date Time <br /> PRKICI�SJON E� O-TECH 545 E Cleveland, St Suite A* Stockton CA 95204*Telephone(209)462-0892* FAX (249)462-7935 4 <br />