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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQ UEST DOCUMENT <br /> CLIENT DETAILS <br /> REPORT INFORMATION <br /> A �• �� Rush Analysis: 5 Days _ 2 Days 24hrs <br /> Client: �Q � � �y1 �,Y'yd7Vt-- Sampler(s): C ' ,"� <br /> Subject to surcharge <br /> Customer Number: <br /> Comp Sampler Set Up Date:— Time: QA/QC report required: yes no <br /> Address: Time: Mileage: If yes,To: State Client Other <br /> Lab number: 5 Q H _1 – 01 <br /> hone: 3 (C r7 r I S <br /> FAX: v A <br /> � � m o o x W <br /> a s`4 o z <br /> Project name: C 49 <br /> c? s t Q N z <br /> Contact person: ( ° <br /> V aF <br /> Q o d z �° cv <br /> SAMPLE INFORMATION 75 4 <br /> Sample Number Location Description Date Time T 5.o w 3 3 3 c <br /> Sa ple Sample F z> w m c?3 Q U <br /> 14 <br /> OD <br /> Relinquished by e Time �`—� Rece' Date7✓ Time 3 /� <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 />