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PRECISION ENVI RO-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS 1 <br /> Client: D i[...�„D?J � :M(0�-�i-1`� l�►�l,Iti1 cL• LI A:G Sampler(s): Rush Analysis: 5 Days _2 Days_24hrs <br /> Subject to surcharge <br /> Customer Number: QA/QC report required: yes no <br /> Comp Sampler Set Up Date:_ Time: <br /> Address: 2_i60 KiLTTiXMAA) Time: Mileage: If yes,To: State �—Client Other <br /> oT t.CD i CA `j 514 1 Lab number: <br /> Phone: (2-0,-L) 33H - We 13 <br /> S 3 Y <br /> FAX: f Loq) 331 - 0-12.3 <br /> m p ro mw o smr o z WM <br /> Project name: PQ <br /> R o <br /> Contact person: 1"a-►_e_ I'I 4 liDC!– <br /> °F z yY z o b u <br /> cu <br /> SAMPLE INFORMATION <br /> Sample Date Time <br /> Number Location Description Sample Sample h z> w 03 w a S U <br /> P F <br /> CUSTOD <br /> Relinquished by: <br /> LIT <br /> 7777Date Z�« Time 1. GS Received b Date Time J ' <br /> L!— <br /> Relinquished by:v 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 />