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M M M M = M M i i � � � � � <br /> PR ISKIN ENVIR®-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS i i <br /> Rush Analysis 5 Days _2 Days_24hrs <br /> Client LL ! 7Sarnpier(s) - <br /> Subject to surcharge <br /> Customer Number QA/QC report required yes no <br /> /� Comp Sampler Set Up Date — Time <br /> Address IC5 { Time Mileage Dyes,To State Client Other <br /> Lab number �'r 7i 0 {� <br /> Phone: x <br /> FAX F a x <br /> A <br /> w Cwt o ro <br /> s z w � <br /> C9 p" p �C <br /> Project name " = E d ° ° <br /> 3G.� 3 q m' <br /> Contact persond o m o w <br /> m z a z f � n <br /> SAMPLE a <br /> d a > a <br /> INFORMATION <br /> Sample Date Time a e a � ��B � � x �-� <br /> Number Location Description Sample Sample P z w 3 a j U <br /> 9 <br /> MO Z_ 1t <br /> L5 Aqk�� now 62f <br /> 1 -JL <br /> 0 -Mg km--L14�-- x <br /> CUSTODY <br /> 7Relinquished by Date��rie eceived by Date 2� Time <br /> Relinquished by ate Time Received by Date Time <br /> Relinquished by Date Time Received by Date Time <br /> PRECISION ENV'IRO-TECH 545 E Cleveland, St Suite A*Stockton CA 95204*Telephone(209)462-0892*FAX (209)462-7935 <br />