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PRE -M' 10N ENVIRO-TECH <br /> CHAIN OF CUSTODY ' <br /> AND ANALYSIS REQUEST DOCUMENT � <br /> I <br /> Rush Analysis 5 Days _ 2 Days_24hrs_ I <br /> Client' lclil k t l YTS Sampler(s) l�� 1�r�i►I c e'� r y� � f_C_i�' l <br /> bo <br /> - Subject to surcharge ; <br /> bo(�_i <br /> Customer Number Comp Sampler Set Up Date — Time QA/QC report required yes no <br /> Address �_���5 S� �� `��'`(AC I`� 1W ' Time Mileage If yes,To Stat'e7 Clirent —Other � <br /> . J Lab number <br /> Phone: x <br /> FAX <br /> '� a sma o z U� mx <br /> c�� - ` y <br /> =/ 140-- s ��rr`l vlr�,ll U Fp o <br /> Project name z <br /> e C7 3 F <br /> Contact person I <br /> ° g a 3 3 R n C f/1 ° G OI <br /> p v 1 <br /> SAM13LE INFORMATION <br /> ET <br /> Date Time a s e a R a m ! r ^p <br /> Location Description Sample Sample z>° w a 4wo y U <br /> ,�- <br /> [ Y <br /> f <br /> Relinquished by A '�f# r�'r •fl�� Date � T,mP� Received by Date Time <br /> Relinquished by Date Time Received by Date Time <br /> Relinquished by Date Tune Received by Date T,me <br /> PRECISION ENVIRO-TECH 545 E Cleveland, St Suite A* Stockton CA 95204 * Telephone(209)462-0892 * FAX (209)462-7935 <br />