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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS ' SAMPLING REPORT INFORMATION <br /> ,)C _ Rush Analysis: 5 Days _ 2 Days_24h <br /> Client:_L' (l� t _ Sampler(s): <br /> Subject to surcharge <br /> Customer Number: D QA/QC report required: yes_ no _ <br /> Comp Sampler Set Up Date:— Time: <br /> //�� //�� V� If yes,To: State Client —Other <br /> Addres :�1j�tl � fff/��` f��f)/�� � /� Time: Mileage: <br /> I h rQ f� ` l/ /A CiG 3�3o Lab number: <br /> Phone: 1 tl1{ ` 0� 3 F <br /> i)`1 j17� �1'1 J� = ' <br /> c) s" <br /> FAX: 7 <br /> sem= g z F <br /> add 9 ax <br /> Project name: a;3 <br /> �� ��1' r�L S e x <br /> Contact person: s E� o m � M m �' <br /> z sem z W $ <br /> A3 M: 8 vl o.Gv m <br /> SAMPLE INFORMATION <br /> e y y Qvx o <br /> Sample Date Time <br /> p Location Description <br /> Number p Sa le Sample <br /> O _IllJ _ <br /> CUSTODY <br /> 7 <br /> Relinquished by: Date ime I tu Received by: Date Time <br /> Relinquished by: Date _Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 7743 N.West Lane, Suite B2*Stockton CA 95210*Telephone(209)477-8105*FAX:(209)477-8148 <br />