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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS SAMPLING OR <br /> Rush Analysis: 5 Days _2 Days_24hrs <br /> Client: 179& h �n� Glc% gS50C.. Sampler(s): <br /> Subject to surcharge <br /> Customer Number: QA/QC report required: yes no <br /> Comp Sampler Set Up Date:— Time: <br /> Address: 22 Time: Mileage: If yes,To: State Client _Other <br /> Lab number: !L} <br /> one: ('20) :367- .370/ <br /> S � x <br /> 3 <br /> K A 4 <br /> FAX: <br /> n s'wc z <br /> CZ <br /> Project name: +PN I.� <br /> zFe N Z <br /> Contact person: DkcyE 4.2 <br /> F zd b z o ro <br /> s <br /> x <br /> m <br /> Q ° z <br /> SAMPLE INFORMATION <br /> p <br /> Sample Date Time y a R y x n ^p x <br /> Number Location Description Sample Sample F z> <br /> Z 3 Zo c,� _S,5A Q- z, ? 3:3S ; 1 <br /> 777CUSTODY <br /> Relinquished by: ate Z&Time 1 Received by: Date a Time 1 <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 />