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IJ _ Page Z of J_ <br /> For Clayton Use Only <br /> �,ClGROU1 SERVICES aytori ANALYTICAL SERVICES REQUEST FOR LABORATORY Date Results Requested: Clayton Lab Project No. <br /> E:)Rush Charges Authorized? Yee XNo <br /> Q Fax or E-mail Re Its <br /> E-mail address: 4A`r`• <br /> Name Client Job No. -05'611.0d Z$.0d Purchase Order No. <br /> Company Dept. Name <br /> Mailing Address Company Dept. <br /> City,State,Zip Address - <br /> • Telephone No. a FAX No. L IF—dt 44 City,State,Zip <br /> Special instructions and/or specific regulatory requirements: Samples are: ANALYSIS REQUESTED <br /> !" (Enter an'X'in the box b I o ate reqest.Enter a'P'If Preservative added.1 <br /> (method,limit of detection,etc.) (check if applicable) 5 Indic <br /> c <br /> ❑Drinking Water g � <br /> U 4 <br /> •�� <br /> E]Groundwater �Q <br /> o � <br /> ❑Wastewater a, ` <br /> 'Explanation of Preservative E <br /> FOR CLIENT SAMPLE IDENTIFICATION DATE TIME MATRIX/ AIR VOLUME = 4 /Q` � USE ONLBY <br /> SAMPLED SAMPLED MEDIA (specify units) <br /> SB^ 16 — N 0 I. 1 ?C <br /> 11.7x--Ij t X <br /> W.f—If' I 01p. <br /> 3•r— ' yj,3,� <br /> f— 6' <br /> , +F <br /> �(rRellnquished <br /> (print) Collector's Signature: <br /> by: DateTme _ Received by:.— DateRme <br /> • <br /> aby: Date/Time S Received by:44 Date/time <br /> pment: Received at ab Date7Time <br /> Sample Condition Upon Receip: Acceptable ❑Other(explain) <br /> Authorized by: Date <br /> Client Signature MAST Accompany Request) <br /> Please return completed form and samples to one of the Clayton Group Services, Inc.labs listed below: DISTRIBUTION: <br /> Detroit Regional Lab Atlanta Regional Lab Seattle Regional Lab White = Clayton Laboratory <br /> 22345 Roethel Drive 3380 Chastain Meadows Parkway,Suite 300 4636 E.Marginal Way S.,Suite 215 <br /> Novl,MI 48375 Kennesaw,GA 30144 Seattle,WA 98134 Yellow = Clayton Accounting <br /> (800)806-5887 (800)252-9919 (800)568-7755 Pink = Client Copy <br /> (248)344-1770 (770)499-7500 (206)763-7364 <br /> FAX(248)344-2655 FAX(770)423-4990 FAX(206)763-4189 9/97 20K <br />