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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SAMPLING REPORT INFORMATION <br /> Client: LIWIE�-5Nw COKM.M/--r/ !a Sampler (s0/1 <br /> Rush Analysis: 5 Days_2 Days_24hrs_ <br /> Composite Sampler Set p: Subject to surcharge <br /> Customer Number: Date: <br /> Time: QA/QC report required: yes no <br /> Address: P'o z ax 3724 Subject to Surcharge Field Sampler: If yes,To: State Client Other <br /> Time Milage: Lab number: (L E S00 4 — O I <br /> Phone: SAMPILE CONDITION <br /> s x Sample Temperature: Celsus <br /> FAX: <br /> w a z = ( ) Leaking. ( ) Broken. ( ) VOA Headspace <br /> Project name: Custody Seal O yes O no <br /> a SAMPLE TRANSPORTATION <br /> Contactperson:- at"i G' �S.t/�// o g o <br /> m °� z3-3 <br /> a a aC� " ( )Ice Chest ( )UPS ( )Fed Ex ( )Drop off <br /> • o e )Other <br /> Sample Date Time <br /> Location Description <br /> Number Sample Sample z> ?a c? <br /> s. <br /> %0u <br /> CUSTODY <br /> Relinquished by: Date 8 ime 1_L1LReceived by: Date �d'gme (1:/V <br /> 77 <br /> Relinquished by: Date _mime Received by: 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. <br /> Page 7of7 <br />