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PREA5IHN ENVIRD-TECH <br /> CHAIN 4F CUSTODY 4r <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS ' i ' INFORMATION <br /> Client: ,� 7&mpler(s) Rush Analysis 5 Days _ 2 Days_24hrs <br /> . ��� <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 <br /> Phone <br /> s d d N <br /> FAX <br /> 000 J <br /> Project name �w - �' , F A a �} CD <br /> Z <br /> Contacterson m o <br /> P <br /> z °z � ~, <br /> a z <br /> c3 day -2 y <br /> SAMPLE INFORMATION <br /> d� 3 <br /> rn 03 <br /> Sample Date Time a <br /> Location Description s o 3 3 <br /> Number Sample Sample z a v_, w cq�l y0 U <br /> M W 5-1;7 /0' 13'-� NP C-�r}! <br /> 9-A 4-c v 41P '--iV <br /> k;2- 2C? P Cr x <br /> P 3 x <br /> A�v 4-114> brkV -3 1 1 <br /> 1 x <br /> ivCSV <br /> 3-1 <br /> REMARKS <br /> CUSTODY <br /> Relinquished b T Date me �'� Received by Date Time <br /> Relinquished by Date Time Received by Date Time <br /> Ckv-dL- <br /> Relinquished by Date Time Received by Date Time <br /> PItEd-SION ENVIRO-TECH 545 E Cleveland, St Suite A* Stockton CA 95204*Telephone(209)462-0892 * FAX (209)462-7935 <br />