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! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! <br /> R Page of <br /> / I Far Clayton Use Only <br /> �-\l�tlaytori REQUEST FOR LABORATORY Date Results Requested: �AkVA Clayton Lab Project No. <br /> Rush Charges Authorized? 0 yea D[J NG <br /> GROUP SERVICES ANALYTICAL SERVICES ) <br /> Q Fax or K F-mall Results <br /> E-mail address: <br /> • Name Client Job No. 40 Purchase Order No. <br /> Company Dept. Name <br /> Mailing Address u • • • Company Dept. <br /> City,State,Zip Address <br /> Telephone No. jjqFAX No. City,State,Zip STE <br /> Special instructions and/or specific regulatory requirements: Samples are: LYSIS EQUEEnt <br /> (method,limit of detection,etc.) (check if applicable) (Enter an W in the box be o indicate request.Fstar a'P'if Preservative added.') <br /> ❑Drinking Water OC <br /> • ❑Groundwater <br /> Wastewater <br /> Explanation of Preservative Poo Y P E <br /> CLIENT SAMPLE IDENTIFICATION DATE TIME MATRIX/ AIR VOLUME Z a�L AQ� �Ja'y USE ONLY <br /> SAMPLED SAMPLED MEDIA (specify units) V �i <br /> Id <br /> oe y, I IK <br /> boo <br /> sfJ- y tyf-� I ►u� <br /> 4— t <br /> fps-3 }.r--8 ' o z <br /> Cg <br /> (print) Collector's Signature: <br /> Ry: DateTme eceived by: ` Date rime <br /> •N Rby: -- n DateTme eceived by: DateTme <br /> MipmateTme <br /> Authorized by: Date Sample Condition Upon Receipt: ❑Acceptable ❑Other(explain) <br /> e MUST Accompany Request) <br /> Please return completed form and samples to one of the Clayton Group Services, Inc,labs listed below: DIST UTION: <br /> Detroit Regional Lab Atlanta Regional Lab Seattle Regional Lab QOOD CONDtON AVS a = Clayton laboratory <br /> 22345 Roelhel Drive 3380 Chastain Meadows Parkway,Suite 300 4636 E.Marginal Way S.,Suite 215 $EAD SPACE ABSENT' CONTAINER Novi,MI 48375 Kennesaw,GA 30144 Seattle,WA 98134 pEL'fiLOA1NAT10]IN LAA ►RESERVE _ ton Accounting <br /> (800)806-5887 (800)252-9919 (800)568-7755 Client Copy <br /> (248)344-1770 (770)499-7500 (206)763-7364 VOA! ORO MRIPALs <br /> FAX(248)344-2655 FAX(770)423-4990 FAX(206)763-4189 9/97 9/97 20K <br />