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POEEI51IN �.:Nktff l-tECH CHAIN OF CUSTODY ' <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS <br /> Client: ��l.W�i `. �IU1'��`( Sampler(s): M 11 Iy Rush Analysis: 5 Days _ 2 Days_24hrs <br /> 1 _ <br /> Subject to surcharge <br /> Customer Number: (y1 QA/QC report required: yes no <br /> Comp Sampler Set Up Date:— Time: <br /> Address: P. U 2-1v✓0 Time: Mileage: If yes, To: State _Client Other <br /> L/)1)1 (A ' Lab number: 1•j 01 t 2 12 — 01 <br /> Phone: Lz Gt�l) 31- 6l,(3 <br /> FAX: <br /> � Z-3 <br /> 2vyl 7 7 7 a _ o g <br /> m S 3 <br /> Project name: <br /> s < H <br /> m -FO A N z F 4 <br /> 6 ^Y <br /> Contact person: CPA L6 N`f 2v <br /> m 'F z <br /> SAMPLE <br /> • <br /> m <br /> Sample + ii3 3Location Description <br /> Sample zNumberSample > <br /> N <br /> CUSTODY <br /> Relinquished b- '- Date ITimc_ (7•-110 Received by: Date ZL Time IL" 4( QV J <br /> Relinquished by: Date Time Received by: Date Time <br /> Relinquished by: Date __Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 3935 N. Coronado Ave. a Stockton CA 95204;' Telephone (209)477-8105 * FAX: (209) 546-7497 <br />