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Clayton For Claylon Use Only Page of <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No. <br /> CONSULTANTS ANALYTICAL SERVICES Batch No. QDI <br /> A Marsh 8 Mclennan Company Client No. <br /> Date Logged In ( 2 q. By <br /> O Name - Title Purchase Order No. I Client Job No. <br /> ¢ co Company r C-L Dept. w LAddre;�sy <br /> e D <br /> a ti Mailing Address o Ua <br /> Lu Z Op /w tS De 1. <br /> cc w Cuy, Stale, Zip >Telephone No. Telefax No. State, ZtP 0A IV L /' <br /> Dale Results Required: Rush❑C la <br /> es <br /> Aut fo�rized? Phone Results Samples are: ANALYSIS EOUESTED <br /> (check if applicable) Z (Enter an•X'in the box below to indicate request; Enter a? if Preservative added. <br /> Special InstrugioPPs: (method, Iir�it of delecc((�on, etc) <br /> a <br /> �pfyPtJS�t S4"sl 'e- 1/`7 3 2l-1 T yr [1 Drinking Water -y <br /> GC419oSit'C SAmt-�I e . 36 -0 L/6 To .�4.,r ❑ Collected in the cg n <br /> Explanation of Preservative: 9 Slate of. New York V <br /> llflX u <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME E FOR LAB <br /> SAMPLED MEDIA (specify units) Z USE ONLY <br /> ///2— SCLC `'Oo'S..-r C) R <br /> a- <br /> < <br /> hl x'CU <br /> CHAIN Relinquished by: Date/rim / 2 Received by: Dalerrime <br /> OF Relinquished by: Date/Time Received at Lab by: DaND I <br /> CUSTODY Method of Shipment: Sample Condition Upon Receipt: Acceptable ❑ Other (explain) <br /> Authorized by: i Dale // 2 �D <br /> (Client Sigr,07ure Must Ac parry Request) <br /> Please return completed form and samples to one of the Clayton Environmental Consultants Inc. labs listed below: DISTRIBUTION: <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd.,N.W. 1252 Quarry Lane WHITE - Clayton Laboratory <br /> Novi, MI 48050 160 Fieldcrest Ave. Suite 490 Pleasanton, CA 94566 YELLOW - Clayton Accounting <br /> (313)344-1770 Edison, NJ 08637 Kennesaw,GA 30144 (415)426-2600 PINK - Client Copy <br /> (201)225-6040 (404)499-7500 6/90 <br />