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I <br /> IF <br /> Fos ClaytoMEMEWO OEM= <br /> n Use Only page _of <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No, �b <br /> CONSULTANTS ANALYTICAL SERVICES <br /> A AUrA A Mclennan Compsrey Batc;`•'No. <br /> Q <br /> N <br /> Client No. <br /> Comp <br /> anyTitleDate Logged fn BY <br /> niam� <br /> Purchase Order No, Client obMailing :•9j Dept. c U Name �- <br /> w U0Y.5tate,Zip 250 O mpany <br /> LLJ Telephone No. - z Address <br /> 7eieiax No, Cit ,State,Zi <br /> Date ResuPs R wired: Rush Charges Authorized? Phone Results <br /> ❑ Samples are: ANALYSIS REQUESTED <br /> pecial hrstrudions:(method.limit of detedion,etc.) (CFleO}c d applicable] (Enter an'X'in the box below to indicate request;Enter a'P'i!Preservative added. <br /> ❑ Drinking Water <br /> 'Explanation of Preservative: ❑Collected inlho43 <br /> TAna State of New York � <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX! Alfa�IOLUME <br /> 5AIAPLED MEDIA (specify units) � FOR LAB <br /> �— r USE ONLY <br /> r <br /> CHAIN Relinquished Date rm <br /> Received by: Datums <br /> Relinquished hy: batafiime �€ <br /> CUSTODY Received at Lab by: -�� Date/Time <br /> Method of Shipment Sample Condition Upon Re t: Acte table <br /> Authorized by: P ❑ Other (explain) <br /> (Client Sf natur.a Must Accompany Request) Date <br /> Please return com feted corm and sam les fo one of fhe Cla on Environmental Consultants,int,labs Iisled below. <br /> 22345 Roelhel Drive Raritan Center 400 Chastain Center Blvd,., , 1252 Quarry Lane DISTRIBUTION: <br /> Nov,,IJiI 46060 16D Fieldcrest Ave. �0- WHITE - Clayton Laboratory <br /> (313)344-1770 Edison.NJ 08637 Suite-09D Pleasanton,CA 94566 <br /> Kennesaw,GA 30144 ° °' (415)426.2644 YELLOW- Clayton Accounting ti <br /> (2D7)225-6040 (404)499.7500 PINK - Client Copy <br /> _ sisa <br /> : <br />