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PRECISION EST,'` IRO- TECH GRAIN OF CUsrrODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> Client: '�1 Lt—Ji r P4L 2(7 t4 Sampler(s): e. Rush Analysis: 5 Days _ 2 Days_24hrs <br /> �,{ Composite Sampler Setup: Svbiect to sax-charge <br /> customer Number: f J Date: Time: QA/QC report required: yes no <br /> Address: �'� �i 1 uU Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> p� Time Mil Q SQ W` 1 10 I <br /> l ) L' age: "t <br /> Uva i C4 - � Lab number: <br /> Phone: I Now <br /> � J <br /> r <br /> M <br /> FAX: ZoQ 7; 0? Z3 � s _ x Sample Temperature: Celsus . <br /> o c x <br /> 9p.° Z o' <br /> Project name:__ R H A b o ( )Leaking.( )Broken. ( )VOA Headspace <br /> M <br /> Custody Seal( )yes ()no <br /> / .SEA N a <br /> Contact person: <br /> SAMPILE INFORMATION <br /> " v a a Ice Chest ( )UPS OTed Ex Drop off ( )Other <br /> M <br /> Sample Date Time E¢ c 3 3 x <br /> Locatior, DescripfJon <br /> Numbcr Sample Sample a > <br /> _ P f P F Z> ink.- m a v m • w Of FA X� <br /> i <br /> Relinquished by: •' Dat /1 r Time �:J(f Received by: DateTime I L6V.`fM <br /> w <br /> (D Relinquish: Date Time Received by: Date Time <br /> Ul Relinquished by: Date Time Received b <br /> M <br /> y: Date Time <br /> 935 N. Coronado Ave. 'k Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br />