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PRECISION ENVIRO-TECH <br />Client: d60651jry <br />Customer Number: <br />Address: P-0 13O)C 3 714 <br />Phone: 09- ¢OZ- 1 h�a <br />FAX: <br />Project name: 134- e <br />Contact person: PON <br />SAMPLE INFORMATION <br />Sample Location Description Date Time <br />Number Samplg I Sample <br />20( <br />Relinquished <br />Relinquished by: <br />Relinquished by: <br />t <br />Sampler (s) - <br />CHAIN OF CUSTODY <br />AND ANALYSIS REQUEST DOCUMENT <br />omp site Sampler Setup: <br />Date: a9 a:/ Time:Og0?! <br />Subject to Surcharge Field Sampler: <br />Time Milage: <br />a <br />0M <br />Rush Analysis: 5 Days _ 2 Days_ 24hrs_ <br />Subject to surcharge <br />QA/QC report required: yes no <br />If yes, To: State Client Other <br />Lab number: 1 C)-} " C) U — U �. <br />Date?#z ime 13dG Received by: <br />Date _Time Received by: <br />Date Time Received by: <br />Date ime 366. <br />Date •1 t' Time <br />Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvleQpetallab.com * www. Page 7 of 7 <br />Sample Temperature: Celsus <br />o <br />� <br />Leaking. () Broken. ( ) VOA Headspace <br />q <br />N <br />u <br />Custody Seal () yes () no <br />^ <br />N <br />z <br />SAMPLE • P • R • • <br />_ <br />o <br />z <br />� <br />( )Ice Chest ( )UPS ( )Fed Ex ( )Drop off <br />$ <br />m <br />)Other <br />7 <br />R <br />s <br />N <br />� <br />O <br />z <br />m <br />• • I <br />A <br />OBTe X178 <br />3 <br />Date?#z ime 13dG Received by: <br />Date _Time Received by: <br />Date Time Received by: <br />Date ime 366. <br />Date •1 t' Time <br />Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvleQpetallab.com * www. Page 7 of 7 <br />