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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLItNT DETAILS <br /> . = POR INFORMATION <br /> Client: <br /> (`,x/4_/ /fir ) In L Sampler(s): •�. n � Rush Analysis: 5 Days _2 Days_24hrs <br /> Composite S ler Setup: Subject to surcharge <br /> i <br /> Customer Number: Date: <br /> // Time: QA/QC report required: yes no <br /> L <br /> Address: ��3 tic,,- A`t Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> Time Milage: y <br /> Lab number: <br /> Phone: f CONDITION <br /> 7=U <br /> s � x <br /> FAX: ("IJ J eY ev u Ck(2f 1.1 tU � - �; 3 o Sample Temperature: , Celsus <br /> o <br /> w � z <br /> Project name: F A b <br /> o O Leaking. O Broken. ( )VOA Headspace <br /> Custody Seal()yes ()no <br /> Contact person: h o S • ' • <br /> s m m <br /> �F z yy b <br /> A " z 333 z <br /> • ' INFORMATIONti 45 )Ice Chest OUPS ()Fed ExjDrop off OOther <br /> M of w = = , 1 <br /> F d <br /> Sample Date Time P _ 333 <br /> Location Description <br /> Sim mpl Sample F z, a m c�3 a vREQUESTED <br /> Number p =o 3 3 �' x z <br /> LL-, z gI Cn i_ 1"J <br /> CUSTODY <br /> Relinquished by: Date i� �G���Received y: Date �Ji�ie <br /> 7 -- <br /> (10 <br /> my I <br /> Relinquished by: Date Time Received by: Date Time <br /> q y: Date Time Received b <br /> �/ Relinquished b <br /> by: Date Time <br /> m <br /> LJ 935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br />