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PRECISION ENVIRO-TECH CHAIN OF CUSTODY <br />AND ANALYSIS REQUEST DOCUMENT <br />Client: "AG-' M vrpl-r),. <br />Customer Number: rill <br />Address: �' V 3�" 2--1 u <br />LA)0, � � _ C1La <br />f <br />Phone: 13 <br />c <br />FAX: <br />Project name: Jfle-r <br />Contact person: to' �6 j�l <br />W1 glop 6 o I <br />Sample Location Description Date Time <br />Number Sample I Sample <br />Sampler (s): <br />Composite Sampler Setup: <br />Date: Time: <br />Subject to Surcharge Field Sampler: <br />Time Milage: <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: Z priY17-0�V - <br />Sample Temperature: Celsus <br />( ) Leaking. ( ) Broken. ( ) VOA Headspace <br />Custody Seal ( ) yes ( ) no <br />( )Ice Chest ( )UPS ( )Fed Ex ( )Drop off <br />)Other <br />D <br />CUSTODY <br />Relinquished byy ' / Date /L 2� ime U Received by: `� / Date <br />Relinquished by: Date _Time Received by: ! Date Time <br />Relinquished by: Date ime Received by: Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvleQpetallab.com * www.petallab.com <br />m <br />G Pa d <br />x <br />O <br />v <br />n <br />w <br />x <br />° <br />o <br />o <br />��a <br />° <br />n <br />C8 <br />z <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: Z priY17-0�V - <br />Sample Temperature: Celsus <br />( ) Leaking. ( ) Broken. ( ) VOA Headspace <br />Custody Seal ( ) yes ( ) no <br />( )Ice Chest ( )UPS ( )Fed Ex ( )Drop off <br />)Other <br />D <br />CUSTODY <br />Relinquished byy ' / Date /L 2� ime U Received by: `� / Date <br />Relinquished by: Date _Time Received by: ! Date Time <br />Relinquished by: Date ime Received by: Date Time <br />3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 * Email: jhvleQpetallab.com * www.petallab.com <br />