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�p a*% <br /> MI m <br /> lTECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS <br /> 7Sampler <br /> ' / ' 1 ' 1Client: N G(Z Sh v �� (n C s): Rush Analysis: 5 Days _ 2 Days 24hrs <br /> Subject to surcharge <br /> Customer Number: <br /> 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: <br /> U <br /> S m <br /> 3 s M <br /> FAX: y m <br /> a v Vj <br /> Project name: Ca ��rt�o �a S P�Z I . e� M N 0 � s <br /> A o <br /> N <br /> a o f(� n O <br /> z w <br /> Contact person: o <br /> d o 44 <br /> a� 33 A V W a <br /> SAMPLE INFORMATION• , g v a3 U �v" r/5 <br /> C4 0 <br /> Sample Date 7Sample <br /> e <br /> Location Description .,0 RR x �� cu <br /> Number P Sample F z a m a 5 U <br /> 4 G IM-1 5 1 <br /> Z� 11 Mw - 3 -- is (4 ss <br /> � z Mw — 3 — zo Is:o <br /> CUSTODY <br /> Relinquished by: D�-,,l U2,n Date lL� 'Time �`� LPN Received by:� �� 'L� Date o '' Time 1' �U <br /> J_ <br /> 777Relinquished 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 />