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M M M M M M M M M M M M i M <br /> !I <br /> PREASIBN ENVIR®-TE <br /> CHAIN OF CUSTODY <br /> CH AND ANALYSIS REQUEST DOCUMENT <br /> DETAILSCLIENT SAMPLING REPORT INFORMATION <br /> y Rush Analysis 5 Days _ 2 Days_24hrs <br /> Client �r�r e3 n'ry ko Sampler(s) <br /> Subject to surcharge <br /> Customer Number Comp Sampler Set Up Date _ __ Time QAIQC report required ye<" ` no <br /> t s <br /> If ye , To State —Client Other <br /> Address Time Mileage / <br /> Lab number <br /> Phone <br /> FAX _ x <br /> � � o <br /> P � <br /> �. <br /> Project name._ <br /> Contact person s -cA�S i v z m z o <br /> -- <br /> a �m � 33� rij o tom d <br /> SAMPLE INFORMATION <br /> m `o 2 �i� 4 c ? 3 V <br /> Sample Date Time m w `� <br /> Number <br /> Location Description Sample Sample z w m 3 a <br /> o <br /> '5— v 14 <br /> k 0 -CW- <br /> 1 . <br /> w �C <br /> 7777 i l Relinquished by t ime w D��Receivedl y ' """� Dates �'�`imeRe niquished by Date Time Received by DateTime <br /> Relinquished by Date -Time—Received by Date Time <br /> PRECISION ENVIRO-TECH 545 E Cleveland, St Suite A* Stockton CA 95204*Telephone(249)462-0892* FAX (209)462-7935 <br />