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11% NZ <br /> t <br /> i <br /> a �t0 <br /> S ,- <br /> ENVIRONMENTAL REQUEST FOR LABORATORY For claycnUsaOn �.�— <br /> v ��;s <br /> CONSULTANTS ANALYTICAL SERVICES Pro;��tN'. :34'500, � U <br /> A Marsh Mclennan Company Batch No- /71 lE <br /> i Client No. 1 r T a <br /> O Name �G,e� <br /> fr rn Company ® Sr 1.r.'k Title Date Logged In S l3Y <br /> C)�- r�P Purchase Order No. <br /> Ul cn Mailing Address « Dept. cwi Name Client reb PJo. <br /> cc�� City,State,Zip' s/ y <br /> z 4 Q".,orrpany <br /> d Telephone No. W> . Address <br /> Date Results Required: Rush Charges Authorized�1efax No. De t. <br /> o' Phone Results Cit ,State, Zi <br /> T,4 i, [j Yes p Sa�imples are: <br /> pecial Instructions:(method, limit of detection, etc) 1 (check if applicable) L ANALYSIS REOUESTED <br /> {linter an'X'in the box beiaw to indica?s re <br /> d Drinking Water ro Gues'.Enter a'P'if Presavativa added. <br /> 'Explanation of Preservative: Collected in the t� ADS} � <br /> State of New York `o <br /> CL1EfVTSAMPLE IDENTIFICATION DATE MATRIX! AIR VOLUME E <br /> SAMPLED- MEDIA (specify units) z <br /> f � <br /> FOR LAB <br /> -6-9 �!1 x� S. ( USE ONLY <br /> - F <br /> � S <br /> r <br /> — a <br /> F <br /> Sr <br /> zi <br /> Relinquished by <br /> CHAIN Da elTm t� <br /> OF Relinquished by: — - �p Received by: <br /> CUSTODY DateTma Date�me <br /> Method at Shipment: _ Received at Lab by: <br /> Sample Condition Upon Receipt: Acce Labia Dat <br /> Authorized by: � A � Ot er (explain) <br /> (Client Signature Musi Accompany Request) Date <br /> Please return com feted form and sem les to one of the Ula on Environmental Consultants,Inc.labs listed below: <br /> 22345 Roethel Drive Raritan Center <br /> Novi,MI 48050 '400 Chastain Center Blvd.,N.W. 1252 Quarry Lane DISTRIBUTION: <br /> 160 Fieldcrest Ave_ Suite 490 <br /> (313j 344-1770 Edison,NJ o8837. Pleasanton,CA 94566 WHITE - Clayton Laboratory <br /> Kennesaw,GA 30144 YELLOW - Clayton Accounting <br /> {201 j 225-6040 (404)499-7500 {415)426 2600 <br /> 6190 PINK - Client Copy <br />