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Iaytprr�� Page—of.— <br /> . l For Clayton Use Only <br /> - REOUEST FOR' LABORATORY Date Results Requested: Clayton Lab-Project-No. <br /> S EBROV A CSE S ANALYTICAL SERVICES Rush Charges Authorized? 0 Yes Q Norr <br /> e Z, <br /> ��7 0 <br /> Q Phone or 0 Fax Results <br /> • Name r Client Job No. q ftT - q< Purchase Order No. <br /> Company L, Dept. Name yA <br /> • Mailing Addis <br /> G L. ` Company Dept. <br /> City,State,Zip L Address <br /> Telephone No. OO '7 O FAX No. (}� City,State,Zip �h '' 14-17 <br /> Special Instructions and/or specific regulatory requirements:" Samples are: AN LYSIS REQUESTED <br /> (method,limit of detection,etc.) (check if applicable) ,�, (Enter an'X'in the box below to indicate request.Enter a'P'if Preservative added.') <br /> Fk4 Rauy ❑Drinking Water <br /> ❑Groundwater <br /> o <br /> ❑Wastewater <br /> Explanation of Preservative la , <br /> E <br /> DATE TIME MATRIX/ AIR VOLUME <br /> CLIENT SAMPLE IDENTIFICATION Z �� FOR LAB <br /> I+ `` vQ SAMPLED SAMPLED MEDIA (specify units) USE ONLY <br /> L7 \� 1J <br /> --A <br /> S <br /> Collected by: (print) Collector's Signature: <br /> Relinquished b : <br /> DateMme eived by: 7V V Date/TlmeVtzlffr7; <br /> ■ Relinquished by: DateMme Received by: DateMme <br /> Method of Shipment: Received at Lab by DateM <br /> YZ 7 r7 U <br /> SamplepoRecei Condition U n- t: []Acceptable <br /> Authorized by:_J_ _ Date p <br /> ❑Other(explain) <br /> CIWM Sigruiture MUST R west <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 San Francisco Regional Lab Seattle Regional Lab White = Clayton Laboratory <br /> 22345 Roethel Drive 400 Chastain Center Blvd.,N.W.,Suite 490 1252 Quarry Lane 4636 E.Marginal Way S.,Suite 215 <br /> Novi,MI 48375 Kennesaw,GA 30144 Pleasanton,CA 94566 Seattle,WA 98134 Yellow = Clayton Accounting <br /> (800)808-5887 (800)252-9919 [8130)294-1755 (800)568-7755 Pink = Client Copy <br /> (248)344-1770 (770)499-7500 (925)426-2657 (206)763.7364 <br /> FAX(248)344-2655 FAX(770)423-4990 FAX(925)426-0106 FAX(2061783-4189 9197 20K <br />