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PR%I5IDN ENVIRD-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT l <br /> CLIENT DETAILS "91114410 i ' <br /> Rush Analysis 5 Days _ 2 Days_24hrs <br /> Client �tl i�n�Q J�n� ]���_ Sampler(s) �n vi r�n�P rr n w �►'�C_, <br /> conenncn J Subject to surcharge <br /> Customer Number <br /> Comp Sampler Set Up Date — Time QA/QC report required yes no <br /> Address 910.5 ,5. f 1 0&0-66 Sf Time Mileage If yes, To State Client Other <br /> 04 52-6 q Lab number <br /> Phone x <br /> 3 <br /> FAX 1 1;11�_r- y ?�' - �(�` , -- - - m o 0a L4 6 <br /> a <br /> cs a ° z <br /> s�o <br /> �I- LoP ��"u M PI2.Pn4 <br /> Project name - a� <br /> � p 4 F"❑ fa N � W� � 0 +y <br /> Contact person L_ 81shan z V m <br /> O r u <br /> � <br /> C ro cd <br /> " �� <br /> E z <br /> 00 <br /> SAMPLE INFORMATION <br /> 0 <br /> Sample Date Time a <br /> Number Location DescriptionDate <br /> Sample z U <br /> I <br /> w1- ryz 3'r7- I �� - 3 K <br /> o1- r5ied 02ST5 k12D3 IZ G -�1 w 3 <br /> tAW)- ST w 3 X <br /> 3 '15 w — X <br /> 6to <br /> u 3'en 3 X <br /> (' <br /> _6LL Cw 3 <br /> 4 Bend- a mI G�1 til <br /> CUSTODY <br /> Relinquished by n Date �rfr�e 9 3 Received by _ i' Datee//24 �tlime <br /> c. fJf 7 ^? Relinquished by Date Time Received by Date Time <br /> a. `;2 Relinquished by Date Time Received by Date Time <br /> PRE16ISION ENVIRD-TECH 545 E Cleveland, St Suite A* Stockton CA 95204*Telephone(209)462-0892 *FAX (209)462-7935 <br />