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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND-ANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS <br /> Client: <br /> Sampler(s): 15 L,{,t,W Rush Analysis: 5 Days _ 2 Days_24hrs_ <br /> ' Composite Sampler Setup: Subject to surcharge <br /> Customer Number: °M Date: Time: QA/QC report required: yes no <br /> Address: S Subject to Surcharge Field Sampler: If yes, To: State_Client Other <br /> La Ii CA 9S -2 \41 Time Milage: Lab number: 6/� q <br /> a S D U I <br /> Phone: 2 041 - 3SAMPLE.CONDITION <br /> s <br /> 3 <br /> FAX: o o Sample Temperature: Celsus <br /> z O <br /> g F Q <br /> E <br /> \'I _ ()Leaking. ()Broken VOA Headspace <br /> Project name: QVC l I W cx e , s g Custody Seal( )yes ()no <br /> SAMPLE TRANSPORTATION <br /> Contact person: 1114ed g o <br /> Ice Chest ()UPS ()Fed Ex kDrop off ()Other <br /> S. <br /> • • '• ON <br /> Pm _ <br /> Sample Date Time <br /> Location Description �o DIN <br /> Number p Sampe Sample z> & mcg w w m <br /> �. ef P& xviz <br /> o� 44 95 z o <br /> i <br /> 114 D10 V41 914 1 CUSTODY <br /> Relinquished Dat Time Re^_eived EZZate Time <br /> Relinquis-ed by: Date -Time-Received by: Date Time <br /> Relinquished by: Date Time R�eived by: Date _ Time <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 54n-7497 * Email: jhvle@petallab.com * www.petallab.com <br />