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PRECISION ENVIRO-TECH <br />Client: <br />Customer Number: <br />Address: <br />Phone: <br />FAX: <br />Project name: <br />Contact person: <br />Sample <br />Number Location Description <br />Sampler (s): <br />CHAIN OF CUSTODY <br />AND ANALYSIS REQUEST DOCUMENT <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: <br />Sample Temperature: Celsus <br />( ) Leaking. ( ) Broken. ( ) VOA Headspace <br />Custody Seal ( ) yes ( ) no <br />( )Ice Chest ( )UPS ()Fed Ex ( )Drop off <br />)Other <br />k777t I CUSTODY <br />Relinquished by: Date Time Received by: 1- 4 ! Date Time <br />Relinquishedby: Date Time 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.petallab.com <br />V <br />o <br />aPQ <br />a <br />o <br />c <br />C7 <br />`� <br />Ca <br />0 <br />•� E" <br />Z <br />II <br />0 <br />a <br />a <br />cm <br />� `° m <br />x <br />cit <br />E+ <br />w m <br />c <br />a <br />Date <br />Time <br />d <br />a <br />d <br />z <br />Sample <br />Sample <br />z > <br />a <br />vai <br />w <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: <br />Sample Temperature: Celsus <br />( ) Leaking. ( ) Broken. ( ) VOA Headspace <br />Custody Seal ( ) yes ( ) no <br />( )Ice Chest ( )UPS ()Fed Ex ( )Drop off <br />)Other <br />k777t I CUSTODY <br />Relinquished by: Date Time Received by: 1- 4 ! Date Time <br />Relinquishedby: Date Time 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.petallab.com <br />