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CNVIRONMINTAL REQUEST FOR LABORATORY R o Clayton Use Only <br /> CONSULTANTS ANALYTICAL SERVICES IecfNo. <br /> A March A ft t enrun Company Batch No. <br /> ( <br /> CfienI No. <br /> 0 Name <br /> s Title Date Logged In 1 1 8 <br /> NN Company Purchase Order No. <br /> Mailing Address Dept. Lu Name Client Job No. moi► <br /> w City,Slate,lip ©� mpany ✓ <br /> t r Telephone No. i U z Address De 1. <br /> Da fi&subs Ra Uir� Rush Charges Ault �phane Results <br /> Cit , State,Zi <br /> as ❑hu Samples are: ANALYSIS REQUESTED <br /> pedal Instructions:(m9lhod•limit of detection, arc.) (Check it appl;Gable) (Euler an'X'in the bo below Io indicate request;Enter a 1P'it Presorval;ve added <br /> Alo)e4r4'd. Z 13 Drinking Wiver c 10 <br /> Explanation of Preservative Tk�K oea't(7� ❑Collecre�•in the 8 <br /> State of New York o {1t <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME E a� <br /> SAMPLED MEDIA (specify units) zFG7R1l6g <br /> USE ONLY <br /> f � r <br /> -7- y a <br /> :I D <br /> r ka - 41 <br /> o r�R <br /> Helinquishad by: - Dale/Time <br /> Roti wahod - Received by: Da1s/Tima <br /> CUSTODY Datefrime Received at Lab by: <br /> Method of Shipment:` , Daleffi <br /> Sample Condition Upon Receipt: XjAcceplable (] Otho (explain) <br /> Aulhorized by: <br /> Date <br /> (CI.vnl Sgnalure Mum Accompany Request) <br /> I71ud5Y rieturn com teled lour and Sam les 10 tine of the Clayton E nvlronawnldl Cun%ull:rnEs, Inc. tabs fisted below:. 'k <br /> r E <br /> 22345 Roethel Drive. Rarilan Center <br /> 'E <br /> ter 400 Chaslarn Center Blvd.,N W. 1252 Ouarry Lane DISTRIBUTION: <br /> f Novi;MI 48050 160 Fieldcrest Ave. Suite 490 WHITE Clayton Laboratory <br /> Kennesaw <br /> (313)344.1770 Edison,NJ 08837 Pleasanton,CA 94556 YELLOW Clayton <br /> ,GA 30144 (415)426.2600 ytonAccourfing <br /> (201)225.6040 (404)499.7500 6190 PINK Cfeenl Copy <br />