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�1 l <br /> Ca 50 iso�� <br /> age , of <br /> REQUEST FOR LABORATORY Project No <br /> ANALYTICAL SERVICES Batch No <br /> Ind Code W P <br /> Date Logged in By <br /> o Name /`/G LI E/l� _ Ttle Purchase Order No Client Job No <br /> rn CompAny Cl'o e Dept w Name t-a W <br /> Marlin Address DO e $ 3 a z 0 Company Dept <br /> City, State, Zi Q u' z Address Lf 4p WRs C r W <br /> Tele hone No ►r, �S.Z- 7 Telelax No �-y$ - $ 3 Z- City, State Zi cc. o <br /> aie Results Req Rush Charges Authorized? P one Fax Results Samples are ANALY S REQUESTED <br /> ❑Yes ❑ No M ❑ (check d applicable) (Enter an'X'in the box below to Indicate request, Enter a'P'if Preservative added ' <br /> )ec�al Instructions (method, limit of detection, etc ) <br /> ❑ Drinking Water <br /> ❑ Collected in the <br /> Explanation of Preservative State of New York 0 <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIRE+VOLUME E FOR LAB <br /> SAMPLED MEDIA s ecif units z USE ONLY <br /> Sp2EAr 7S 1 X x ti <br /> q,2 19-g e i -Z <br /> 4 <br /> _ H <br /> GZS�,qo�-7t <br /> PGH ,« - <br /> '�+►,�►^ t'4'Sss�.)`+ , e."'�'' a�(Cti t{7�rt�` r� '} S!s'�'eA x+"'i 1-+ti� Rf+"�';��.�e <br /> Collected by �. �Sir (PfIt11 M Cal�ecipr'j Sig <br /> CHAIN Relinquished by D e/Tim �%h Received by - ~ D�dy +r , <br /> OF <br /> USTODY Relinquished by Date/Time Received at ab by Da e1Ti e _ <br /> Method of Ship*nt Sample Condition Upon Receipt ❑ Acceptable [] Other (explain}":;', <br /> ,ulhorized by Date ' <br /> (Chant Signature Must Accomp?sly Request) :Y <br /> Fe,so relurn completed form and samples to one of the Clayton Environmental Consultants Inc labs listed below <br />