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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> 77 <br /> ' CLIENT DETAILS <br /> REPORT INFORMATION <br /> Client: f:' Sampler(s): Rush Analysis: 5 Days _ 2 Days_24hrs <br /> Subject to surcharge <br /> Customer Number: Comp Sampler Set Up Date:— Time: QA/QC report required: yes no <br /> Address: If yes,To: State Client Other <br /> Time: Mileage: �r-ff (` <br /> Lab number: ,5C `� 2_Sy F— <br /> Phone: "J <br /> FAX: �W q J 6 P <br /> cpm o a s <br /> a 8w c o z a <br /> Project name: 0 <br /> o c? <br /> v-ta A N z E+ o Z <br /> a W W <br /> Contact person: 1 e- o o a v <br /> F z 3 z z�z <br /> m a R ro <br /> I •0. ��„ 3 3 `" x <br /> "c r11 SAMPLE, INFORMATION -ol <br /> U �ro U1 <br /> e d .6 0M <br /> Sample Date Time d e¢ a 3 v, x `'1 <br /> Location Description =0 3 3 <br /> Number p Sample Sample z> w 9 3 � w � � � 00`-1� U <br /> CUSTODY <br /> r <br /> 7777Relinquished b Date5Time 1O-�V Received by: o �'\ Date55Time �� <br /> Relinquished by: 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 />