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PR,ECISIO.N ENVIR,O-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> ( <br /> Client: Sampler Sam Rush Analysis: 5 Days _ 2 Days 24hrs <br /> - p <br /> Customer Number: <br /> Composite Sampler Setup: Subject.to surcharge <br /> Date: Time: QA/QC report required: yes no <br /> Address: Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> Time Milage: <br /> Lab number: <br /> Phone: 5 SAMPLE CONDITION <br /> s _ <br /> � F: <br /> FAXt a v Sample Temperature: Celsus <br /> � mx 3 _ x <br /> m o o x <br /> y W o A c ZO <br /> x n ( ) Leaking. O Broken. ( )VOA Headspace <br /> Project name: � o b 1 <br /> �; a ° Custody Seal ( )yes ( )no <br /> o <br /> o <br /> Contact person:_ N s o • • <br /> a oG <br /> °F z o <br /> z <br /> 111)Ice ChestOUPS )Fed Ex (;)Drop off )Other <br /> SAMPLE • • v <br /> of � oA o <br /> Sample Date Time 3 mLocatioDescription 0 Number Sample Sample z o m v Nx <br /> z° <br /> ' A <br /> 11 <br /> Relinquished by: Date Time Received by: Date Time <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: ihvle@netallab.com * www nat.nllnh rnm <br />