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w w w w w w w w w w w w w w w w w w w <br /> � Page-3 of <br /> For Clayton Use Only <br /> _�Cjaytori REQUEST FOR LABORATORY Data Charts Authorized? , Clayton Lab Project No. <br /> GRaUY SfRVICES <br /> ANALYTICAL SERVICES Rush Charges Authorized? Yes ® No <br /> - Q Fax or E-mail Results <br /> E-mail address: <br /> 1 <br /> • Name Client Job No. _ , as Purchase Order No. <br /> Company AWL I 1AA I ,• Dept. Name <br /> Mailing Address Company Me Dept. <br /> City,State,Zip Address <br /> • Telephone No. FAX No. 17 City,State,Zip <br /> Special instructions an /or p ci is regulatoryrequirements: <br /> (method,limit of detection,etc.) (check If applicable)amples are: n YSIS REQUESTED <br /> (Enter an in the box p indicate request.Enter a'P'N Preservative added.? <br /> ❑Drinking Water c <br /> El Groundwater <br /> S <br /> El wastewater Vim' n <br /> Explanation of Preservative <br /> CLIENT SAMPLE IDENTIFICATION DATE TIME MATRIX/ AIR VOLUME z' J��Q� V FOR LAB <br /> SAMPLED SAMPLED MEDIA '(specify units) USE ONLY <br /> W—!r -IV ( Arr 1W <br /> a-r IV,r—if ' I 11or <br /> y / lydr <br /> '6 r- I /y/a <br /> / W X <br /> NO <br /> lIf-fG ' r o X <br /> /Syo <br /> Collected by: 1 (print) Collector's Signature: <br /> Relinquished by: DateRm Received by: atemme <br /> Relinquished by, DateTm - Received by: Date/Time <br /> Method of Ship nt: ` Received at Lab by: / Da Ime <br /> Sample Conciti Re ei t: cept le er(explain) <br /> p: Date <br /> Ghent Si nature MUST 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 <br /> 22345 Roethel Drive 3380 Chastain Meadows Parkway,Suite 300 4636 E.Marginal Way S.,Suite 215 White = Clayton Laboratory <br /> Novi,MI 48375 Kennesaw,GA 30144 Seattle,WA 98134 Yellow = Clayton Accounting <br /> (800)806-5887 <br /> (600)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 />