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ENVIRO-TECH i CHAIN OF CUSTODY , <br /> AND ANALYSIS.REQUEST DOCUMENT <br /> CLIENT DETAILS I SAMPLING REPORT INFORMATION <br /> Client _AD J 1 M Rush Analysis 5 Days _ 2 Days_24hrs <br /> Sampler(s) �• <br /> Customer Number -- <br /> Subject to surcharge <br /> Comp Sampler Set Up Date — Time QA/QC report required yes no <br /> Address TimeMileage if yes, To State Client Other <br /> Lab number �IC <br /> Phone <br /> U <br /> � u h <br /> N <br /> FAX <br /> O 6 Cir v) <br /> Project name W - 6s F p Q g I a <br /> • � ° <br /> oFQ a N z o <br /> Contact person _ w� y o <br /> 1 o <br /> F z �y z o W �� <br /> CU <br /> SAMPLE INFORMATION <br /> T7 <br /> Sample Date Time 9¢ �'`� 0 0 <br /> Number Location Description s <br /> p e Sample F =� <br /> 1�U --� ll 1 3•� CT <br /> CUSTODY <br /> Relinquished bye ' /Z T�me � <br /> 7 -- Recewed by Dad"- line_�,._ <br /> !77 <br /> Relinquished by Date Time Received by _Date Time <br /> Relinquished by Date Time Received by Date Time <br /> PRECISION ENV'IR.O-TECH 545 E Cleveland, St Suite A* Stockton CA 95204 *Telephone(209)462-0892 * FAX (209)462-7935 <br />