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l l I dnAIIN uh a Ug-.WD I , <br /> y A c5 <br /> PRECISION ENVIRO-TECH ANDANALYSIS REQUEST DOCUMENT <br /> hti: 11 www Precision Lab. Com <br /> CLIENT DETAILS • REPORT INFORMATION <br /> `1 ' }l ( �._ t (_ Sampler(s): Rush Analysis: 5 Days _2 Days_24hrs <br /> Client: i -�/ - <br /> Subjectto surcharge <br /> Customer Number: <br /> 4. Comp Sampler Se7TT_n_._.— me:_ QA/QC report required: yes no <br /> Address: Time: Mileage: <br /> If yes,To: State _Client Other <br /> Lab number: <br /> Phone: z <br /> FAX: A w 9 e <br /> z ~ w x <br /> Project name: d �d•tt.A Irk 6 $ 01 <br /> IC F 2 <br /> �e g <br /> Contact person: e r q 1 m <br /> 'r o o :� d <br /> I h m X' y` .� z <br /> b N tl vd <br /> Sample SAMPLE INFORMATION Date Time <br /> Number Location Description Sample Sample z'>° a � 5 ? co'�> U <br /> E/KT 1W rr /S 3:e7P (r ,< x <br /> / <br /> 1 14 DIVA F.1 14 <br /> r <br /> CUSTODY <br /> a <br /> Relinquished by: Date Time Received br- /� Date / / ime <br /> Relinquished by: Date —Time-Received by: , Date Time <br /> Relinquished by: Date Time Received by, Date Time <br /> PRECISION ENVIRO-TECH 2040 E. Harding Way SuiteB*Stockton CA 95202*Telephone(209)462-0892*FAX:(209)462-7935 <br />