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PRECISION ENVIR(ImTECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQ UEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> r L C j Rush Analysis: 5 Days _ 2 Days_24hrs <br /> Client: T(� Sampler(s): �71�D - l� <br /> Subject tb surcharge <br /> Customer Number: QA/QC report required: yes no <br /> Comp Sampler Set Up Date:— Time: <br /> If yes, To: State Client Other <br /> Address: v �a Timer Mileage: <br /> r <br /> Lab number: 503 011-L Q <br /> Phone: 2 1—7576 1 <br /> FAX: 209_3(0'7_ <br /> b0d3 x d � <br /> Project name: �; z <br /> R to G N m O v <br /> Contact person: .D) H-a L4 d z o a " <br /> W ro <br /> C11 <br /> SAMPLE INFORMATION <br /> Sample Date Tiime a o a 3 3 �' x O <br /> Number Location Descrlptlon Sapp le Sample z a -c?� � 2 � U <br /> 6eAN 0 17-7- 30UM a� oc 1,I <br /> CUSTODY <br /> Relinquished by: _ Time F,� geeei by: Date p Time <br /> 7- <br /> Relinquished by: Date Time Received by: Date—. Time <br /> Relinquished by: Date Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 7743 N.West Lane, Suite B2* Stockton CA 95210 *Telephone(209)477-8105 * FAX: (209)477-8148 <br />