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PRECISION O-TECH CHIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> ' <br /> DETAILSCLIENT 'O' INFORMATION <br /> Client: 1`)C0� � '� ! W ? Sampler(s): i Rush Analysis: 6 Days _ 2 Days_24hrs <br /> Composite Sampler Setup: I Subject to surcharge <br /> f Customer Number: Date: Time: � � QA/QC report required: yes no <br /> Address:_� ���X Subject to Surcharge Field Sampler: � � If yes,To: State Client Other <br /> j � !,'� Lab number: <br /> Time Milage: O�l 2 Z 2� l f <br /> �) �"f <br /> Phone: Uog� �T�`�� f�61 '5 _ i I , � _ USAMPEE CONDITIO <br /> + I - = i _ _ Sample Temperature: Celsus <br /> FAX <br /> w .=9 . O G r <br /> leaking.{ )Broken.( )VOA Headspace <br /> name: <br /> Project _ <br /> J ,. j . F � Custody Seal( )yes ( )no <br /> N I y <br /> Contact person: E 0 <br /> s z ? (XIce Chest ( )UPS ( )FedEx )Drop off ( )Other <br /> SAMPLE INTFORMATION <br /> Sample Date Time Z o r1_i y< 3 s n <br /> Location Description = c N1 - <br /> Sample rr z> <br /> Number Sample ; <br /> AUXT& lt1�t�- e '?I ci7 E SfifT-12- f-z? 12: 0 - 6 - "ir 1 <br /> i <br /> I <br /> i <br /> i i 1 9 -TF 1 <br /> • iCUSTODY <br /> Re➢inquished by: Data e Received _ DatL•'�ZZ ime IZ14K <br /> Relinquished by: Date Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Date Time <br /> I <br /> 3935 N. Coronado Ave. * Stockton CA 95204 Telephone (209) 477-8105 FAX: (209) 546-7497 * Email: jhvleQpetailab.com * www.petallab.com <br />