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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS ' REPORT • ' • <br /> (' 7Spler(s): (c�A�CU f / � Rush Analysis: 5 Days _ 2 DRYS _ 24hrs <br /> Client: �� vn ar� l�u�Dh4 —� <br /> Composite Sampler Setup: <br /> Subject to surcharge <br /> Customer Number: Date: <br /> Time: QA/QC report required: yea no <br /> Address: Subject to Surcharge Field Sampler: If yes,To: State r,Clienzt,—Other <br /> Time Milage: Lab number: <br /> Phone: ZQ°l 33N 6G13 MUM • • <br /> FAX. Sample Temperature: Ce'SUS <br /> 4 sia a 6 z i <br /> a ;o ° r O Leaking. O Broken. (�VOA Headspace <br /> Project name: F%n6 goo o� /'�I�no� Su ZK(G3 3Es Custody Seal( )yes (AID <br /> e � c SAMPLE • • <br /> Contact person: 4n L� d 4 A z z o <br /> r ��:� <br /> a 3 3 z ( lice Chest ( )UPS OWed Ex ( rop off ( )Other <br /> SAMPLE INFORMATION <br /> Sample Date Time <br /> p Location Description <br /> Number p Sample Sample z> <br /> 07 33��/ F.�c Rood 3/31 t ;h5 �► TJ� I`h f-> 1 BC <br /> Relinquished by: 13�G�l C�) H4np�� I Date & Time (41• 110 Received Date*(Wime/4 : I li <br /> Relinquished by: Date __.Time Received by: DateTime _ <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 * ww Page 6 of 1 1 <br />