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���� For Clayton Use Onty Page, 01 <br /> ENVIRONMENTAL REQUEST FOR LAiORATORY <br /> Project No <br /> T <br /> CONSULTANTS ANALYTICAL SERVICES Batch No Q <br /> Client No <br /> A Wnh a mdemm CempM <br /> Date Lagged in By <br /> Tdle Purchase Order No Ghent ob .437-6491100 <br /> Namf�e S Name <br /> C �nY Dei - <br /> P �n11 e t <br /> Mailing Address D <br /> R W.State,IpAddress <br /> Telephone Alo Telefax No Cd .State Z <br /> D uRush Charges Ay homed? Phone Results Samples Bre I" ANALYSIS REQUESTED <br /> e Results R 0 <br /> � - � ❑Yes 13 {Check d 2�ppftcal7le) m (Enter an•X'in the box below to mdrrate request,Enter a�'d Preservative added <br /> peml WructioriL(method,Gmd of detection,etc) ❑ Dnnkmp Water 'E <br /> h <br /> /E�O�Z+er41r Z &APO'— -rT- 4&1,44) ❑Collected to the <br /> 9- -'16 <br /> •Explanafon of Presen WWW �s4E State of New Yolk $ �Q?' <br /> DATE MATRDU AIA VOLUME Q FOR LAB <br /> CLIENT SAMPLE IDE1+i MATION SAMPLED MEDIA (speody Unds] Z USE ONLY <br /> r <br /> _ e. <br /> C)3- <br /> okufthonzed <br /> Relinquished 'PEI r <br /> Date un Received by Datelfune <br /> DateITuns Received at Lab by --� Dateffrrne <br /> Relinquished b9l Acceptable Other(explain) <br /> Method of Shipment: Sample Conddion Upon R p ❑ <br /> by* Data <br /> (Client Signature MOMAccompany <br /> �Rqu' �)est <br /> Please retum com eted form and Sam tea to one at the Clayton Environmental Consultants,Inc labs E�sted below DISTRIBUTION <br /> 400 Chastain Center Blvd,N W. 1252 Quarry Lane WHITE - Clayton Laboratory <br /> 22345 Roethel Drive Raritan Cerdw leaPsanton,CA 9456F, YELLOW - Clayton Accounting <br /> Novi•I,AI 48050 160 Fieldcrest Ave Suite 4913 Pleasanton. <br /> PINK - Gerd Coq <br /> (313)344 1770 Edison,NJ 08837 Kennesaw,GA 30144 ( )476 6190 <br /> (201)225-WO (404)499-7500 <br />