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PRECISION ENVIRO-TECH CHAIN OF CUSTODY AND ANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS INFORMATION <br /> Client: lac h Axxod I Pokx�i'c S <br /> 7Sampler(s):11'�J;Jy(Y1�� Qx� Rush Analysis: 5 Days _2 Days_24hrs_ <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: <br /> Date: Time: QA/QC report required: yes no <br /> Address: (Y�h64cvl 3{e4,C� J!t Subject to Surcharge Field Sampler: If yes,To: State Client Other <br /> 4, c� C <br /> Time Milage: 1 G 2 —.0 <br /> 1 <br /> Ckv,h � <br /> aa- v+ . Weir- Lab number: <br /> .M - t <br /> 'hone: tog-y X3- �Y?S'1 — 52-5- T-19-606 SAMPLE CONDlrjrlON <br /> S x <br /> 3b Sample Temperature: Celsus <br /> FAX: o 4 I a _ ac <br /> a w g F5 a 0 z <br /> a o; ( )Leaking. ()Broken. ( )VOA Headspace <br /> Project name: uN 21 GinnAe h+'4; �A Custody Seal( )yes ( )no <br /> z • <br /> Contact person: • <br /> 2 fib'-31 Z <br /> )Ice Chest ()UPS ( )Fed Ex ( rop off ( )Other <br /> SAMPLE INFORMATION <br /> �F c 3 <br /> Sample Date Time a ` w° `�c 3 A <br /> Location Description a o a x zANALYSES <br /> Number p Sample Sample P z> a yv w R <br /> r q:3 C ZC — S — C <br /> Z. ' 10 ;06S <br /> o; — <br /> 4 LC5 p — <br /> % <br /> ct F P, - 1 12 1 41 <br /> • , CUSTODY <br /> Relinquished by: Date��Time .36 Received by: Date Fime Ta' <br /> Relinquished by: Date Time Received by: Date Time <br /> Relinquished by: Date Time Received by: Date Time <br /> 3935 N. Coronado Ave. *Stockton CA 95204*Telephone(209)477-8105*FAX:(209)546-7497*Email:Petal545®sbcglobal.net*www.petallab.com <br />