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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> REPORT INFORMATION <br /> CLIENT DETAILS V <br /> D4 ALJ ��P"1�� Sampler(s): Rush Analysis: 5 Days _2 Days_24hrs <br /> Client:_ 1\ 0 , <br /> Composite Sampler Setup Subject to surcharge <br /> Customer Number: fl a Date: Time: QA/QC report required: yes no <br /> Address: <br /> Q 0, leo, 21 Ou Subject to Surcharge Field Sampler: if yes,To: State Client Other <br /> F �r ) cA S��i Time Milage: <br /> Lab number: 1 Q O 3 <br /> r <br /> Phone: �{- fir"f ! • <br /> k s . <br /> FAX: <br /> Sample Temperature: Celsus <br /> U sm� z <br /> A a m <br /> Leaking. O Broken. { )VOA Headspace <br /> Custody Seal es no <br /> Project name: ' � � A ��3 �_ N � y ( }y ( ) <br /> Contact person: TRANSPORTATION <br /> • # # p d d b 3 �(pIce Chest ()UPS ()Fed Ex *Drop off ( )Other <br /> Sample <br /> Date m <br /> Location Description m z°Number Sample Sample e a' �' 3 d s z 4 • A <br /> N W <br /> E <br /> ILA DIVIII V.,11 CUSTODY <br /> 4 <br /> k <br /> I <br /> E , <br /> �r. . f yy , <br /> Relinquished by: Date Time z~�� Received by: Date�Time 1 <br /> Relinquished by: Date Time - ._ Received by: Date Time <br /> Relinquished by: Date Time Received by: Date Time <br /> 3935 N. Coronado Ave.*Stockton CA 95204*Telephone(209)477-8105*FAX: (209)546-7497*Email:Petal545@sbcglobal.net*wrvw.petallab.com <br />