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Clayton For ClayWn Usc my Page <br /> Pioietl No 24.s.3 � <br /> ENViRONMENTA REQUEST FOR LABORATORY <br /> Client No <br /> CONSULTANTS ANALYTICAL SERVICES DDateReecc <br /> ate eived gholko BY <br /> A atarsh b Mttennan Campant • Date logged In —4- By <br /> Purchase Orden No Client Job NoA!2-5'31. Q d O Name Ak�r. <br /> A fS tine Y' e:N ,Y1-eP V <br /> Name —`r L I1 nr + Q% U�✓t 's' ¢m Company ,4 i1 r. v,Vi a�r�l v7A L � L-'r <br /> W <br /> Com an Dept 0 t Mailing Address .2 c� ✓ G ri1 - <br /> W p P Y 1e N t W w City State Zip J'a G ►' ; <br /> to Addreao 2 Teletex N (' <br /> Stato,ZI ! Tele hone No <br /> TFO <br /> Oit <br /> gal _R� s Requtr Rush Charges Authorized? ANALYSIS REOU .Ent <br /> G!µ 47 1 9-70 ]Yes ❑ No (Friar en x in the boa nelt�v to Indrute rAgnestEnt a a ti PreeprtrAthlr ade.d') <br /> �4n tiv <br /> Special uuctbns (method,limit of detea:tlon,phony result.rush resuda,etc) � (J <br /> 0,1e WQek 7vrrt Q�'ovµ 1'"2,T!/�f� r <br /> •Eaplanstlonof P[esuvauve 7� �aUl�r 1. 0 <br /> p r-� ta <br /> �v y <br /> DATE MATRDU AIR VOLUME 0 7 p FOR LAB <br /> CLIENT SAMPLE IOENTIFlCATit]N SAMPLED MEDIA ispecity units) ` USE ONLY <br /> _ I <br /> Df- <br /> - <br /> x CV <br /> sQ <br /> CHAIN Relin u1shed bit <br /> 1 /t/t"! Dale Time pr} Received b VAtp Ime <br /> OF Date Time Received at lab b slate Ime 15 <br /> CUSTODY Ill. <br /> uisdad b <br /> Sample conddion upoIreceip <br /> (y tequlied) Method o!shi eni /I <br /> Aulhorll ed tki a L Date n J <br /> (Ghent Stgnstum Must Accompany Request) - <br /> DISTRIBu flON <br /> please return completed form and sem les to one o1 the Cis an Environmental Consultants Inc labs listed below W NiTE Clayton Laboratory <br /> 221 is Roethel Drive Raritan Center 400 Chastain Center Blvd,N W 1252 Ouatry Lane <br /> H r rl Ml 46050 160 Fteldc reel Ave Suite 494 Pleasanton,CA 94566 YELLOW - Clayton Accounting <br /> i71 tl 344 1770 Edison NJ 08637 Kennesaw GA 30144 (415)426 2600 PINK =Client Retains <br /> (201)225 6040 499 1500 <br />