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PRW151DN ENVIRD-TECH CHAIN OF CUSTODY n � Z <br /> AND ANALYSIS REQUEST DOCUMENT4,, � 7- <br /> CLIENT DETAILS m==7 I <br /> REPORT INFORMATION <br /> 1 Rush Analysis 5 Days _2 Days_24hrs <br /> Client 1 iCi� 1(ATCt�I[ �rl�PS Samplers) �C:i' Cl�rvC� <br /> —) � �} � � Subject to surcharge <br /> Customer Number QA/QC report required yes no <br /> Comp Sampler Set Up Date — Time <br /> Address ?SOS S 1 Time Mileage If yes, To State Client Other <br /> S- plc cn Lab ber bbIX 10 tZ, <br /> Phone <br /> FAX v R E Y 3 0 x <br /> Protect name trc frtn t v w <br /> L� q a 0 <br /> Contact person ri z y y ° z gr Cd <br /> SAMPLE INFORMATION -6, g, <br /> TmeSample Date a <br /> Location Description Sample Sum le <br /> Z> <br /> t t <br /> D5 — g S 1 9 0 0 Cr 1"1 l; r�j► 7C X K x <br /> 50 A - 5 x x x x <br /> CUSTODYf <br /> Relinquished by nate 1z(�t "Time Received by . Date 1 0 ITime Zj1b <br /> Relinquished byzz;�Date <br /> Time Received by Date/-2" 6XV <br /> Relinquished by Date Time Received by Date Time <br /> PRECISION ENVIRO-TECH 5415 E Cleveland St Stnto A t Stockton CA 9r>204 t TolephonP(209)462-08921 FAX (209)962-7935 <br />