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Clayton For Clayton Use Only Page of <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No. <br /> CONSULTANTS ANALYTICAL SERVICES Batch No. qDI O <br /> A Mash d Mclennan Company Client No. <br /> - Date Logged In 11 7- q O By <br /> O Name Title Purchase Order No. Client Job No. <br /> ¢ rn Company r G-L Dept. w LAddress <br /> ,XJ, <br /> o- Mailing Address Z Qany C—T--f- Dept. <br /> fr w City, State, Zip N z ar Telephone No. Telefax No. — State, Zi / <br /> Date Results Required: Rush Charges Au orized? Phone Results Samples are: @ ANALYSIS EQUESTED <br /> ❑ Yes ❑ (Check 8 applicable) c (Enter an'X'in the box below to indicate request; Enter a'P'if Preservative added. <br /> pecial Instruclioq: (method, lir�it of detecc��on etc. <br /> (pr'r1�r)5 Sr.^1I"Lt 2� Drinking Water y i <br /> LCr'11��5ift SA/Nt,,J-L 36 -0 L/6 To { Collected in the 3 nv <br /> Explanation of Preservative: 9 State of New York 5 V <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME E ��� \x FOR LAB <br /> SAMPLED MEDIA (specify units) Z USE ONLY <br /> Lq C7 <br /> a- <br /> // Z L <br /> F1 ACU <br /> CHAIN Relinquished by: Dalelrim�/ 2 Received by: DateMme <br /> OF Relinquished by: Datelfime Received at Lab by: Da <br /> CUSTODY Sample Condition Upon Receipt: Acceptable Other (explain) <br /> Method of Shipment: P Po P ❑ P ❑ <br /> Authorized by: Date <br /> (Client Sig ure Must Acco pany Request) <br /> Please return completed form and samples to one of the Claylon 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 08837 Kennesaw,GA 30144 (415)426-2600 PINK - Client Copy <br /> (201)225-6040 (4D4)499-7500 6is0 <br />