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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br />AND ANALYSIS REQUEST DOCUMENT <br />REPORTCLIENT DETAILS SAMPLING <br />Client: L>> UoO -J ?� %l un.1=%'E"i Sampler (s): j =t I`LLL Rush Analysis: 5 Days _ 2 Days_ 24hrs <br />Customer Number: <br />Composite Sampler Setup: <br />Date: Time: <br />Subject to surcharge <br />QA/QC report required: yes no <br />Address: 5/1-7 L -i 11LAL, <br />Gj� Zy <br />Subject to Surcharge Field Sampler: If yes, To: State Client Other <br />Time <br />Milage: <br />�� � "7 <br />Lab number: <br />Phone: l Z�% `'/ 3 3{ - G� I .�SAMPLE <br />CONDITION <br />FAX: <br />p <br />Q <br />d <br />Sample Temperature: Celsus <br />z( <br />) Leaking. () Broken. ( ) VOA Headspace <br />Project name' ���`"'U�' <br />s <br />3 <br />� <br />� <br />Custody Seal () yes () no <br />z <br />z <br />Contact person:�� l_GLn <br />Pif <br />a <br />a <br />C7 <br />0 <br />w <br />`. <br />t <br />x <br />m <br />♦ • • ♦ • <br />. <br />U <br />fw <br />m� <br />A EF <br />c <br />www <br />m <br />O <br />� <br />• ♦ <br />� <br />db. <br />�y <br />> <br />( )Ice Chest ( )UPS { )Fed Ex ( )Drop off <br />SAMPILE • <br />• <br />o <br />w .. <br />a <br />o <br />�7 <br />o <br />0 4 <br />)Other <br />Sample <br />Description <br />Number <br />Date Time <br />Sample Sample <br />d <br />s c <br />w <br />rR <br />z <br />zLtion <br />♦ ' A <br />3 <br />�CUSTODY <br />Relinquished by. Date Eljr& ime (Z ', -5q Received by:--' ;77-- Date ime L <br />Relinquished by: "'4r I Date mime Received by: Date Time <br />Relinquished by: Date mime _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 />