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of � <br /> PR 15l�N ENVlRD TECH CHAIN OF CUSTODY urwfMW <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> Client &,Jt -(L— wq L L i Lus 7smpler(s) Rush Analysis 5 Days _ 2 Days_24hrs <br /> U <br /> Subject to surcharge <br /> Customer Number QA/QC report required yes no <br /> Camp Sampler Set Up Date — Time <br /> Address '3105 Time Mileage If yes, To State Client Other <br /> '�7 5 2 Lab number <br /> Phone a�-'c Ci Li -- <br /> FAXx - A <br /> =a3 ° <br /> 0 A W <br /> Project name <br /> 4 P <br /> Contact person oc-i Rt--IjA . 1 <br /> U v 1 w m m w m �- <br /> tia z ar <br /> 333 x C! USAMPLE INFORMATION. j <br /> to <br /> Sample Location Description Date Time R o w Q o <br /> Number Sample Sample F z y 5 U <br /> t- - 6 6 � <br /> it 1' sr <br /> d- d= �t �� � Y LTJ x <br /> f tr 610 � <br /> ►� �' ' ? C P <br /> t 1 ren tr .�, C G <br /> IOUSTOY... <br /> y Dat <br /> Relinquished b C7 ime 5 F <br /> q � Received by - Date <br /> Relinquished by Date 'Time Received by Date Time <br /> Relinquished by Date Time Received by Date Time <br /> PRECISION ENVIRO-TECH 545 E Cleveland, St Suite A x Stockton CA 95204*Telephone(209)482-0892 * FAX (209)482-7935 <br />