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S�HN ENVlRL]-TECH i CHAIN OF CUSTODY � <br /> P REAAND ANALYSIS REQUEST DOCUMENT <br /> INFORMATIONREPORT CLIENT DETAILS SAMPLING <br /> f 6- 7a�1� �� 1 Sampler(s) L Rush Analysis 5 Days _ 2 Days_24hrs <br /> Client &62--o <br /> Mc Subject to surcharge <br /> Customer NumberCamp Sampler Set Up Date Time QA/QC report required yes no <br /> f j <br /> Address Time Mileage��a If yes,To State Client Other <br /> � � � ' <br /> Lab number 17006 -0 1 a q <br /> Phone x <br /> u M A ti <br /> FAX Vs�: 63 9 4'Ic 2 t 1 �3 6 o w <br /> m a � �x <br />� Project named ��__G rl 71r ❑� "1 <br /> z <br /> Contact person a ° <br /> 1�0 °E" O 4g, <br /> RI e <br /> SAMPLE INFORMATION <br /> Sample Date Time d ¢ a 3 x Z m <br /> Number Location Description gamp]e Sample � 11z��� 11 ° p 3 3 <br /> 4 °'t/ l �' -7 6 6 <br /> /nGuJ ,l ]� NP Qw11� X <br /> Ym�c1 9 ► G 6 W �v <br /> MW <br /> • • • CUSTODY <br /> Relinquished by Date Time Received by Date tla4une q`3 <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* Stockton CA 95204*Telephone(209)462-0892 *FAX (209)462-7935 <br />