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'.a to ForCla�o Usa7y <br /> ENVIRONMENTAL REQUEST FOR LABORATORY P oldct N' 3 4150 o. G U <br /> CONSULTANTS ANALYTICAL SERVICES Batch No <br /> A MAnh 8 MAtOmAn ComP+r+y Clio-it No <br /> Data Logged In S Bir <br /> a Narre;&—W :5r A.y;r' Title P4rchsse Order No o(an Joh No <br /> Compary Q z uF Dept uu Name G 1-✓ <br /> Mailing Address 0 OCompany Dept <br /> CCn Cay,State,Zip L i~Address <br /> M Telephone No Telefax No — City,State Z. <br /> Duty Results Required Rusts Charges Authortzed1i Phone Hasults samples are ANALYSIS REQUESTED <br /> T� r• yes N0 (check tf applicable) m (Enter an X in the box be o+v to+nd cava regjas Enna, a P if Pra-errat vo added <br /> c <br /> penal Instructions (method,luno of detection, etc) Q Drinking Water <br /> Woj24114f, Z 1tJB6 K T �.tLrq�2du+i2j Q Collected In the <br /> Explanation of Preservative Stare of New York <br /> K� <br /> CLIENT SAMPLE 1DENi71'1CATION DATE MATRIX! AIF(VOLUME �v`•� �'yJ t1\� FOR lA9 <br /> SAMPLED MEDIA (specify units', z S!/ A �� y USE ONL <br /> 13 <br /> t <br /> Air— 1 <br /> —3 S <br /> — <br /> Ar"' <br /> F <br /> Ea <br /> elT,� DatelTirne <br /> CHM Relinquished by "En fJ _ �� Received by <br /> OF Relinquished by paie�me Received at Lab by Dat <br /> CUSTt7DY Method of ShipmenL Sample Condition Upon Receipt Acceptable [] Ot er(explain) <br /> IL <br /> Authonzed by <br /> (Client Signature Bust Accompany Request) <br /> Please return compleled form and samples to one of the Clayton Environmental Consultants Inc labs listed below DISTROUTiON <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd N W 1252 Quarry Lane WHITE Clayton Laboratory <br /> Mom,Ml 48050 160 Fieldcrest Ave Suite 490 Pleasanton,CA 94566 YELLOW Clayton AccounOrg <br /> (313)344 1770 Edison,W 08937 Kennesaw,GA 30144 (415)426 2600 6194 PINK Client Copy <br /> f (201)225-6040 (404)499 7500 <br />