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PREIFISKI N ENVIR® TEC14 CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SAMPLING ' ! ' ! ' ! <br /> Ir Rush Analysis 5 Days _ 2 Days___24hrs <br /> ClientAt-I i fn,a-Ta— 1 c Lt&t 5 1N1�, - Sampler(s} n <br /> Subject to surcharge <br /> Customer Number QA/QC report required yes no <br /> Comp Sampler Set Up Date Time <br /> 3 f 00facin � If yes,To State Client Other <br /> Address J Time Mileage <br /> CL Lab number <br /> Phone <br /> s <br /> v <br /> y R <br /> FAX <br /> m G <br /> Project name6 ,f/ y �, <br /> � t y� I <br /> rl'15 <br /> Contact person l� �R- I V,.3 o v m CU <br /> m <br /> oy z 3 x r °° <br /> SAMPLE <br /> i ' • i of 1E = R� v - <br /> o ix <br /> Sample Date Time v Q w° 3 �, m x d <br /> Location Descriptio o a ggco <br /> Number p Sample Sample z a a m c?3 a U <br /> i ,Qle se I USE11/11 1 35 C7 tl(-, V r, 6 <br /> Mwj 11 hi 5oXi I: <br /> i <br /> CUSTODY <br /> Relinquished by Datd Vwsme /,"'TOO Received by main Date *21 T.e q'25A <br /> Relinquished by Date w"Time 11�eceived b Date Time <br /> r� r <br /> Relinquished by Date Time Received by Date U Time <br /> 7 ---7----------PRECISION ENVIRO-TECH 7743 N West Lane, Suite B2 * Stockton CA 95210 *Telephone(A 47Y-8105*FAX (209)477-8148 <br />