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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br />AND ANALYSIS REQUEST DOCUMENT <br />Client:'� ��ow Ul�+ro!!IA( <br />Customer Number: <br />Address: 7;�'* '%oX 2,060 stn N • C -W;' <br />Phone: <br />FAX: <br />znm N . (Ppm, "1 <br />Project name- ` - *tl- ng -L 9'Sz:rl <br />Contact i • 1 M 2 `tKT 1`. <br />Sample Location Descri tion <br />Number p <br />Relinquished by: <br />Relinquished by: <br />Relinquished by: <br />Date I Time <br />Sampler (s): 11Z 1 C'TP'rJ <br />Composite Sampler Setup: <br />Date: Time: <br />Subject to Surcharge Field Sampler: <br />Time Milage: <br />Rush Analysis: 5 Days _ 2 Days_ 24hrs_ <br />Subject to surcharge <br />QA/QC report required: yes no <br />If yes, To: State Client Other <br />Lab number: / d L/ / L /9_0 <br />U <br />s Sample Temperature: Celsus <br />O � <br />z e () Leaking. () Broken. ( ) VOA Headspace <br />Custody Seal () yes () no <br />� z <br />ii ep ♦ I ♦ • <br />z ° <br />( )Ice Chest ( )UPS ( )Fed Ex ( rop off <br />m )Other <br />d <br />z <br />11 DOFA <br />Date N 'ime P-30 Received b- <br />Date —mime Received by: <br />Date —Time Received by: <br />DateA#412ITime ` 3 <br />Date Time <br />Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle®petallab.com * www. Page 7 of 7 <br />4 <br />d S <br />° <br />oda <br />Gm a <br />•� <br />� <br />F A <br />d <br />°. <br />z <br />, <br />31 <br />6 <br />a <br />SA <br />aaa <br />b„ <br />° <br />65 <br />° <br />z> <br />a <br />P /I/ <br />I "1. � <br />Rush Analysis: 5 Days _ 2 Days_ 24hrs_ <br />Subject to surcharge <br />QA/QC report required: yes no <br />If yes, To: State Client Other <br />Lab number: / d L/ / L /9_0 <br />U <br />s Sample Temperature: Celsus <br />O � <br />z e () Leaking. () Broken. ( ) VOA Headspace <br />Custody Seal () yes () no <br />� z <br />ii ep ♦ I ♦ • <br />z ° <br />( )Ice Chest ( )UPS ( )Fed Ex ( rop off <br />m )Other <br />d <br />z <br />11 DOFA <br />Date N 'ime P-30 Received b- <br />Date —mime Received by: <br />Date —Time Received by: <br />DateA#412ITime ` 3 <br />Date Time <br />Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle®petallab.com * www. Page 7 of 7 <br />