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��11 <br /> I ISKI '\I ENVIR0-TECH CHAIN OF CUSTODY i <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS HIPWORTINFORMATION <br /> 01 l / Rush Analysis 5 Days _2 Days^24hrs <br /> nY ins hl� L1�hel- �n� 7&�npler(s) ' 4v �.r�aCllerit' � Subject to surcharge <br /> Customer Number. C rL <br /> Comp Sampler Set-Up Date Time QA/@C report required yea no <br /> Address 310mi C I 0I: iD 57-• Time Mileage If yes,No State Chem Other <br /> T"ocgr 7-01 CA -5-2 a d <br /> Lab num r, 15 1 G t <br /> Phone-.. 9 * 66 -3. s 4- <br /> a p � <br /> Project name:_ ! �` 20 S .i 'ra <br /> U <br /> Contact person. X&c J31S , <br /> SAMPLE INFORMA.140N <br /> SamplaI�OCZ tIOIt Description Date <br /> Number P Sample <br /> w /A 4G 3'G kA Grw I ac X x X Ix <br /> w - z ix G sq- r x' x x Jif <br /> w a '= G 5 G I� &W f 3 X X XC <br /> � !� �o o �' Cr' '5G fir G=w � 311, X -A <br /> ti <br /> CUSTODY <br /> kIL <br /> f °6A , ISA <br /> Relinquished by. Dattr 2 -tim + Received by Dat k-L ima <br /> Relinquished by� l Date) Arkme 12 GHQ t zecaived by Y'+ �� Date `� Z T'Anie <br /> 77!7 <br /> Y <br /> Relinquished b Date Time Received by Data Time <br /> q <br /> PRECISION E�qV O-TECH 545 E, Cleveland,Suite,A* Stockton CA 95204*Telephone(209)4P2-0892*FAX (209)462-7935 <br />