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PRECISION E NVIRO-TECH CHAIN OF CUSTODY <br /> AND 1NALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS O ' <br /> Rush Analysis: 5 Days _ 2 Days_24hrs v <br /> Client: � v t-_ Sampler(s): <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: — Date: <br /> Time: _ QA/QC report required: yes no <br /> Address: Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> Time Milage: <br /> Lab number: <br /> Phone: • <br /> s � z <br /> 3 s <br /> FAX. � ,� � Sample Temperature: Celsus <br /> C7 a ,� m u b O <br /> g .� z S <br /> = a ° a L: i O Leaking. O Broken. ( )VOA Headspace <br /> Project name: s c 3 <br /> Custody Seal <br /> no <br /> `fig mz SAMPLE TRANSPORTATION <br /> Contact person: _ m o z s z o <br /> s <br /> a <br /> )Ice Chest ( )UPS OWed Ex Drop off ( )Other <br /> SAMPLE INFORMATION 5 <br /> Sample Date Time <br /> Number Location Description Sample Sample z <br /> 1 ,P <br /> 17 <br /> Z 3; <br /> i>114 D10 V.1 <br /> . <br /> ti CUSTODY <br /> d Relinquismed by. Date Time Received by: Date.' Time <br /> Relinquis'=ed by: Date Time Received by: Date Time <br /> � x <br /> Relinquisted by: Date Time Re-eived by: Date Time <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 54--3-7497 * Email: jhvle@petallab.com * www.petallab.cor_ <br />