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PRE&SKI V ENVIR[]-TECH CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> ' REPORTCLIENT DETAILS SAMPLING <br /> &Van (rp C{' K! Sam Ier Rush Analysis 5 Days 2 Days�,,,24hrs <br /> CIient .� .,r n M,,;� p (5) l � <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 x <br /> FAX -2 L 7 Zf 6Y 3 R - o r A <br /> m� <br /> TfbDPCIL <br /> � a z/� � aiProjectMame'_ ,— ORL� � U Yca3 �' ¢ F+ <br /> o o $ 0 <br /> 9Fe o N w o z <br /> Contact person Q 1� F v <br /> v cr- q z J z o <br /> �2 <br /> SAMPLE INFORMATION <br /> Sample Date Time 5¢ w° 33 x <br /> Number Location Description Sample Sample F z' a m 3 a a a <br /> 4v l Q L r "V 9 <br /> I <br /> 7CUIY <br /> STOD <br /> r <br /> Relinquished by DateLV`/r�Time_ Received by Date � Time Zz <br /> Relinquished by Date Time Received by Date Time <br /> Relinquished by Date Time Received by Date Time <br /> - 771 <br /> PRECISION ENVIRO-TECH 545 E Cleveland, St Suite A * Stockton CA 95204 *Telephone(209)462-0892* FAX (209)462-7935 <br />