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PRECISION E NVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> SAMPLINGCLIENT DETAILS ' • ' T INFORMATION <br /> Dr' [ (} ((W k- Sampler (s : YV ' Glr �jN�1 1 1awlflush Analysis: 5 Days 2 Days—24hrsClient: <br /> r, n Composite Sampler Setup: Subject to surcharge <br /> Customer Number: Date: <br /> tt Time: QA/QC report required: yes no <br /> Address: �' �I Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> Time Milage: 2CG 6 214 <br /> 2A I <br /> Lab number: a <br /> Phone: C�t1C M2r (5 • • <br /> U <br /> F, A 3 m Sample Temperature: ° C_ Celsus <br /> * �4 c o <br /> r" '' ( M o; o z M O Leaking. O Broken. ( ) VOA Headspace <br /> Project name: I G) Y�� �— A 4 Q N ° Custody Seal ( ) yes ( ) no <br /> in <br /> 0. c? F q A z <br /> II <br /> Contact person: ' ' • • • • <br /> l kiN, <br /> o a x <br /> O <br /> � a w m m O <br /> a 3 <br /> d 3 Oaa E ox <br /> z° <br /> ( )Ice C <br /> hest )UPS )Fed Ex <br /> )Drop of <br /> r)Othe03SAMPLE INFORMATION =q - .Sample Date Time 8c a2 <br /> Location Description Sample REQUESTEDNumber ple <br /> OD <br /> Relinquished Dae, Time = �� Received Date ime L [ <br /> Relinquished by: Date -Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Date ►ime <br /> 7711 <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvleQpetallab.com * www.petallab.com <br />