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EN"RO- TECH CHAIN OF CUSTODY <br /> I I�,E C I S I ON AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> I , m <br /> Sampler(s): <br /> StA., <br /> l�MI', <br /> m�� E <br /> Rush Analysis: 5 Days _2 Days_24hrs <br /> Client: ���C� C�'�"�"' � �V � �'" <br /> Subject to surcharge <br /> oniposite Sampler Setup: <br /> Customer Number: V tom-- Date:_ T Time: QA/QC report required: yes no <br /> �� I Subject to Surcharge Field Sampler: If yes,To: State Client Other <br /> Address: <br /> Time--- Milage: _ <br /> — Lab number: <br /> L/ SAMPLE CONDITION <br /> Phone: 2 S i -- _ <br /> 2O 2 w mx 3 x Sample Temperature: Celsus <br /> FAX: _ " <br /> a <br /> o <br /> V� <br /> -p; () Leaking. ( )Broken. ( )VOA Headspace <br /> � <br /> 1. ! <br /> Project name• , ° F ° Custody Seal O yes O no <br /> 4 <br /> • $ Y oFa a N z TRANSPORTATION–,i • • <br /> Contact person: f J <br /> ° z m °= o <br /> Q: <br /> Q <br /> d z )Ice Chest ( )UPS ( )Fed Ex ( )Drop off ( )Other <br /> ° °s <br /> � 5 3 <br /> SampleDate Time E a G S 3 z • <br /> Number Location Description Sample Sample F z° a. g a S a` Q <br /> RC1 <br /> &I I 7- So <br /> 0 L S S �i/1 L_V'5 <br /> i <br /> , <br /> . � CUSTODY <br /> Relinquished Date7 Time �� "L &Received by: Date IIime ���,��,�, <br /> Relinquished by: Dated Time' aReceived by: G�/"��- Date-7A l�me <br /> Relinquished by: Date Time Received by: Dae__ Time i <br /> 3935 N. Coronado Ave. *Stockton CA 95204 Telephone(209) 477-8105 FAX; (209)546-7497*Email: Petal545@sbcglobal.net '`w,;w.petallab.com <br />