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MP MN ENV1RD-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS <br /> INFORMATION <br /> p Rush Analysis: 5 Days _ 2 Days_24hrs <br /> Client: � G P� ��4-h _�-�-- 1�� Sampler(s): � �ti�uY�r 1 <br /> �. Subject to surcharge <br /> Customer Number: <br /> Comp Sampler Set Up Date:_ Time: QA/QC report required: yes no <br /> Address: 31S W . PIn Time: Mileage: If yes, To: State Client Other <br /> I I ck 9 5')_4f C) Lab number: <br /> Phone:_ <br /> S x <br /> FAX �� o9) 3 - S319 <br /> z <br /> x o <br /> Project name: I ZS ;('R. • D 6 F A o o <br /> j s <br /> N <br /> Contact person: n 1�r C\'V Jk S 2.2 a d o <br /> m m 0 _ <br /> c� z 33� z W <br /> o SAMPLE INFORMATION <br /> CoA o � v a' <br /> Sample Date Tima e¢ a 33g v x <br /> Time <br /> 1 C4 <br /> a <br /> Number Location Description Sample Sample F z o a 3 w y U <br /> i Mw AMT S 7 <br /> `�t 3w - - i s 9 ; , <br /> 1S + Mw ► - 20 9 :t'7 <br /> n MW - -2- -- I(D _7 <br /> 18� -7 M MvJ fin/ — ( ( S <br /> — 2 _ <br /> zo %AW 3 5 30144 <br /> 7OD <br /> Relinquished by: ��)QA )\((14 Date iWaWime 'Ll' Received by: frim, <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 />