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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br /> CLIENT DETAILS AND ANALYSIS REQUEST DOCUMENT <br /> REPORT INFORMATION <br /> Client: d i Sampler(s)_ ���y Rush Analysis: 5 Days _ 2 Days_24hrs <br /> C K T Composite Sampler Setup: Subject to surcharge <br /> Customer Number: Date: <br /> r� f Time: QA/QC report required: yes no <br /> Address: SL _( �/ � � Subject to Surcharge Field Sampler: If yes, To: State Client Other <br /> Q s 3?b Time Milage: `�.� (-a <br /> Lab number: 2 Q -� 2-a3 <br /> Phone: �� � � . <br /> /� S 4 <br /> x <br /> FAX: ��� V �; - _ x F7Sample Temperature: Celsus <br /> a o <br /> z akin Broken.Project name: 5 s amg• () ( )VOA Headspace <br /> ody Seal()yes ()no <br /> Contact person: <br /> 0 <br /> c �� o. 33 m n' x <br /> 4 . 7 . w 3 a v ()Ice Chest ()UPS ()Fed Ex (Drop off ()Other <br /> w F p ti 0, m p d <br /> Sample Date Time A <br /> i23 <br /> 1LGJ IV <br /> {{//Ci <br /> Number Location Description <br /> Sample Sample F Z.° a 3 m a m • <br /> 1 1 6 n:� C—x • <br /> TA <br /> LU OD <br /> Relinquished by: Date ime_ ` Received by: <br /> Relinquished by: Date Time Received by: Date Time <br /> Relinquished by: Date Time Received b <br /> TC'. 935 <br /> y: DateTime <br /> N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br />