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PREEISIG I ENVIRQ-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CUMM���� M�= <br /> � 7RushCt: Analysis: 5 Days 2 Days_24hrs c� '{_ <br /> 7Sanipler7_�� <br /> Subject to surcharge <br /> Customer Number: <br /> Comp Sampler Set Up Date:_. Time: QAIQC report required: yes no <br /> Address: Time: Mileage: If yes,To: State Client Other <br /> Lanumber:1�� I ^ d <br /> P�ne: <br /> � _ x <br /> d � m <br /> FAX: x A <br /> � a rm m � � <br /> 3m a m 6 <br /> Project name: " a <br /> b 4 x <br /> U � G <br /> C7 a R <br /> Contact person: <br /> z Rqa 6e? ms <br /> w � U = W q V <br /> Samplea <br /> Number Location Description Date Time 1 o 4 1 F F <br /> '�o0 <br /> 39 SSample Sample - w' met @ a z ��0 U <br /> 3 <br /> ! 7-0 l:odiw 01 P ✓ 1 DNI <br /> um <br /> Relinquished Date 11 Time—IL--2?4Ae-Received by: Date 1�- t2!-Time S�'. ,0 <br /> Relinquished by: Date Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Data Time <br /> PRECISION 19NVIR.O-TECH 545 E. Cleveland,Suite A* Stockton CA 95204*Telephone(209)462-0892*FAX:(209)462-7935 <br /> -J ..J J --•J _ ..� ..�.1 _...1 <br /> _.J J LJ J ..J .J J '.J L...J I_,.J <br />