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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS <br /> MM REPORT • ' • <br /> Client: oan11b.14 "Act,i Sampler(s): <br /> Rush Analysis: 5 Days _2 Days 24hrs <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: *� � Date: <br /> I ! Time: QA/QC report required: yes no <br /> Ad ress: -� t ( U-17-4- N-t.� Subject to Surcharge Field Sampler: If yes,To: State_ _Client _ _ Other _ <br /> XC4 � 5,2 <br /> 2� Time Milage: <br /> m l 1' Lab number:_ a <br /> Phone: (aoct ('y(03 -.5 I Ll • • • <br /> U <br /> FAX: S 4 - m G 3 _ Sample Temperature: 4.3 0� Celsus <br /> VA <br /> � ;� o <br /> ` a C . <br /> o z c <br /> I��� r O Leaking. O Broken. ( )VOA Headspace <br /> Project name: w 28 <br /> v-- U 3 Custody Seal() es no <br /> O V <br /> N y () <br /> Contact person (, � - �' o � - � • • <br /> `F z z o <br /> z <br /> SAMPLE INFORMATION <br /> . • 3 x lce Chest ()UPS <br /> OFed Ex ()Drop off )Other <br /> of <br /> Sample Date Time E¢ a' v,n y N z <br /> Number Location Description Sample Sample F z> 0. c�-5 A <br /> ' O 13'•22 - - (; L <br /> N . - - <br /> CUSTODY <br /> a Relinquished by. atd '+ IIime YI 2.16 w eceived by: V Date Time �3 <br /> rCDD <br /> Relinquished by: Date TimeReceived by: DateTime <br /> p zo Relinquished by: ---Date Time Received by: Date Time <br /> 4 - <br /> 935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle®petallab.com * www.petallab.com <br />