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I I I I 1 I I i I I I I 1 I I 1 1 I [ <br /> PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> m CLIENT DETAILS I <br /> � �,f n t ♦ <br /> i 1 1?t101N(M + �S S b L Rash Analysis: 5 Days _2 Days_Mrs_ <br /> a Client: a Sampler 10149 �c a <br /> Customer Number: Subject to surcharge <br /> Comp Sampler Set Up Date:_ Time:_ QA/W reportrequired: yes_ no <br /> Address: 011,2- {x otn!s d u,� UJ <br /> Time: Mileage; If yes,To:State —Client —Other <br /> 4-D <br /> ZT-D Lab number: <br /> Phone: 3( I - 3-'O y <br /> FAX: CA — `}Z—Z <br /> e �_ Im= � z S mqB-• <br /> Project name: <br /> a s4 FQ z <br /> a Contact person: tiAA t&<< a Eo v` s s o w <br /> UJ Z y x rn �a <br /> S c U <br /> SAMPLE INFORMATION <br /> t - o mat D 'y D A <br /> Sample Date Time <br /> on E< w i3 m g <br /> Location Description EE ag Z s <br /> Number Sample Sample <br /> aro S• e�r . <br /> M <br /> n <br /> m <br /> r <br /> 0 <br /> r <br /> e <br /> M <br /> m � <br /> e i <br /> mm Relinquished by: Date Time 1•� Z �• e //D�••' /A <br /> Received b <br /> NRelinquished by: Date _Time Received by: a Time <br /> Relinquished by: - Date _Time Received by: ate Time <br /> m <br /> PRECISION ENVIRO-TECR 7743 N.West Lane,Suits H2*Stockton CA 95210*Telephone(209)477-8105*FAX;(209)477-8148 <br />