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Im <br /> v ®n <br /> C \ f For Claytor,Use Only 1fage _o( <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No. <br /> CONSULTANTS ANALYTICAL SERVICES <br /> Batch NO. <br /> in 5oLt <br /> Marsh&Mclennan Company' Client No. <br /> Date Logged In gy <br /> F O Name /]1`�A Tide Purchase Order No. Client lob No. 3� <br /> Company o P w Dept. w . Name <br /> D Mailing Address U Company t, De <br /> t.y, tate, p: ` <br /> ess <br /> Telephone No. Telefax No, rn CddrState,Zi <br /> Data Aesuks A uirsd: Rush Charges Authorized? Phone Resuks Samples are: ANALYSIS REQUESTED 0 Yes M No ' © (Cht;clt'tf appGCabiO) (Enter an'X'in the box below to indicate request;Enter a'P'if Preservative added. ' <br /> Special Instructions:(method.limit of detection,'etc.) <br /> ® Drinking Water <br /> nlpl�vtq-sem Z v!'arr_ R .4K Collected in the cg <br /> 'Explanation of Preservative: State of Now Yank <br /> 1/ <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME E 0 (�A V� FOR LAB <br /> SAMPLED MEDIA (specify units) Z ( , (� �0 USE ONLY <br /> 7 S-7-- ffy a XP <br /> XPT- 3 Ak <br /> CYiIUN Rekirtquished by: D teTme 1G Received by: Date�me <br /> OF Reiinqu'Med by: DatelTme Received at Lab by: �• D <br /> CUSTODY <br /> AAethod of Shipnent: Sample Condition Upon Receipt: Acceptable ❑ OfheF(explain) <br /> Authorized by: ZI _ Data SrZ-9� <br /> (Client Signature Must Accompany Request) t <br /> Please return completed form and samelss to one of the Clayton Environmental Consultants,Inc.labs listed below: <br /> DISTRIBUTION: <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd.,N.W.. 1252 Quarry Lane WHITE - Clayton Laboratory <br /> Novi,MI 48050 160 Paldcrest Ave.' Suite 490Pleasanton,CA 94566 YELLOW - Clayton Accounting <br /> (313)344-1770 Edison,UJ 08837 Kennesaw,GA 30144 (415)426.2600 PINK - Client Copy <br /> (201)225-6040 (404)499-7500 6190 <br /> f . <br />