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�"``+� CHAIN OF CUSTODY <br /> P R I S I G N ENVIRO=TECH 1 AND ANALYSIS REQUEST DOCUMENT ) <br /> CLIENT DETAILS SAMPLING, REPORT INFORMATION <br /> Rush Analysis: 5 Days _ 2 Days_24hrs <br /> Client:, .vr-+"rd) is ;j1,t�-G2CYL�Jytc Sampler(s): w�! <br /> Subject to surcharge <br /> Customer Number: Comp Sampler Set Up Date:. Time: QA/QC report required: yes no <br /> Address' Time: Mileage if yes,To: State Client Other <br /> • Lab number: <br /> Phone: x <br /> . s -- <br /> a = P <br /> FAX• " 6 b <br /> w ¢cMO <br /> o N x <br /> m b G <br /> 0 <br /> Project name: �'L s 3 <br /> N - - <br /> U z <br /> Contact person: -9 ° �' coo q ` ro <br /> 5Ez z <br /> qQ d 3 3 300 <br /> FORMATION <br /> SAMPLE IN <br /> Sample Date Time v w x p <br /> Number Location Description Sample Sample z' U <br /> 24 31 ✓ <br /> • ,� N15A xix <br /> f <br /> 1 5 5 <br /> V 1 ~ ;55 <br /> 'CUSTOD <br /> Relinquished by: Date Time e Received by: � t-tom - DatTime Y40 <br /> Relinquished by: Date Time Received by: Date Time <br /> ---------------------------- <br /> Relinquished by: Date Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 2040 E.Harding Way Suite B* Stockton CA 95202*Telephone(209)462-0892*FAX:(209)462-7935 <br />