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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORT • ' • <br /> Client: 1r l f/ v , ll;( Sampler(s): Rush Analysis: 5 Days_2 Days_24hrs_ <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: Date <br /> Time: QA/QC report required: yes no <br /> f <br /> Address: Subject to Surcharge Field Sampler: If yes, To: State—Client Other <br /> Time Milage: <br /> Lab number: <br /> Phone: <br /> xSAMPILE CONIDITION <br /> 6m 3 <br /> Sample_ m Temperature: <br /> Celsus <br /> z <br /> ki <br /> ()Lean roken. ( )VOA Heads ace <br /> o; <br /> Project name: o g' O BP <br /> N Custody Seal O yes O no <br /> Contact person: r' �: � C �{ /i v 1 "`"} o ; z ' ' ' ` • ' ` • <br /> J m c h 333 w <br /> • • e` o ° o v ()Ice Chest ()UPS ()Fed Ex ()Drop off ( )Other <br /> of Q „ h o <br /> Sample Date Time <br /> Number Location Description z <br /> Stopl Sample <br /> a <br /> 7 . <br /> Relinquished by: ' sit>E t�' •1 ' - �i Date--�,Tlm 'i 1-' Received by ( F Date <br /> L <br /> Relinquished bj�i Date Time Received by: 1 Date Time <br /> Relinquished by: Date _Time Received by: Date Time <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br /> �K< "R a <br />