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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SAMPLING1 1 1 <br /> Rush Analysis: 5 Days _ 2 Days_24hrs_ <br /> Client: ,�SEL C)- 1�ni�DE4S 6,-J Sampler(s): <br /> Subject to surcharge <br /> Customer Number: QA/QC report required: yes <br /> ADO Comp Sampler Set Up Date:— Time: no <br /> A <br /> Address: cZ2 O 6�r L� Time: Mileage: If yes, To: State Client Other <br /> L-UQZ GA 967!10 Lab number: 16 10 1 -01 <br /> Phone: 4-201) 534,2 - 370 / U <br /> S 3 M <br /> FAX: � <br /> - A <br /> a [gym s s � <br /> add v <br /> ° •G y aJ I C4 <br /> Project name: S► E U��S ^PR o P 'T'i __ F <br /> a a zFA o z d� Z <br /> Contact person: <br /> z v z o <br /> a3 w <br /> 9 �� Z a� J u' � U ❑� � <br /> SAMPLE INFORMATION <br /> Sample Date Time a ¢ a y m ! y <br /> Location Description o a 3a y v <br /> Number Sample Sample P z a �2in a <br /> r � <br /> 77777 CUSTODY <br /> Relinquished bate Time Receive - Datme <br /> Relinquished by: Date Time Received b/ 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 />