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MXIMFrUSTDI" r �r <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CILIENT DETAILS REPORT <br /> -� Rush Analysis 5 Days _2 Days_24hrs <br /> Client Sampler(s) �UCLt'lsC�r'1 <br /> u I r n ria D C,rik-- r" Subject to surcharge <br /> Customer Number J, QA/QC report required yes_ no <br /> Camp Sampler Set Up Date — Time <br /> Address*r. Time Mileage If yes,To State Client Other <br /> Z Lab number <br /> Phone E <br /> y Sr <br /> V <br /> v <br /> FAX h <br /> Protect name ti o/J�f— <br /> I <br /> Contact person � ►0� -rL V1� 1 ki c. - - d xocc <br /> 3 C' 4+�1"4d�Sample Date7'LmeNumberLocation Description Sample Sample <br /> mw�t ob <br /> us-� i�'r�— ,,� � NP <br /> �� <br /> CUSTODY <br /> Relinquished Dst Received by VI/ _T Dat77 �me � <br /> Relinquished by DaAhwhw me Received by_ Datol�&ime <br /> Relinquished by - - - - Datel/ TLme Received by Date Time <br /> PRECISION ENVIRO-TECH 7743 N West Lane, Suite B2 M Stockton CA 95210*Telephone(209)477-8105 FAX (209)477-8148 <br />