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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS REPORT INFORMATION <br /> Client: 0 6 � Sampler(s): <br /> Rush Analysis: 5 Days _ 2 Days_24hrs <br /> �'; — <br /> Subject to surcharge <br /> Customer Number: A C report Comp Sampler Set Up Date:— Time: @ R p t required: yes no <br /> Address: Time: 0; 00 Mileage: If yes, To: State —Client —Other <br /> Lab number: <br /> Phone: <br /> � _ x <br /> FAX: A <br /> a a <br /> Q v x <br /> Project name: 1 `,^JY111(1 N, i �. vt�7 - x"�P l° A _ o a <br /> F <br /> � 5 5 <br /> Z <br /> Contact person: �' < r t I -- N= o o - o" <br /> °� z a z o apj v <br /> '- 03SAMPLE INFORMATION <br /> aaa 6 oma v <br /> Q <br /> Sample Date Time <br /> Number Location Description Sample Sample z°a w 3 m a a , U <br /> ,2 VG, 01eII zf� V : vJ Grp _ – <br /> ce 1 <br /> FFFI <br /> 1"A M1 R11 H <br /> tl <br /> i <br /> Relinquished by:1�. Dat z�- Timet2 2.�7—Received by: .i. - Date Time <br /> Relinquished by: _Date _Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Date Time <br /> PRECISION ENVIRO-TECH 7743 N. West Lane, Suite B2 * Stockton CA 95210 *Telephone(209)477-8105 *FAX: (209)477-8148 <br />