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I <br /> Cayton I For Clayton Use Only ?age ) <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Protea No <br /> CONSULTANTS ANALYTICAL SERVICES Batch No <br /> A MaM 3 Md.ennw Caa4wvy Client No <br /> Date togged In BY <br /> O Name Ic.v'gr Title Purchase Order NoClient Job No 3-2- <br /> r� Company �ppLj pko <br /> 00A&a IDepL Name <br /> Maung Address o S2mpany De <br /> Crly,State,ZipPI <br /> 60� Address <br /> Telephone No Telefax No City.State,Zi <br /> Date Results R uired I Rush Charges Authonaedl Phone Results Samples are ANALYSIS REQUESTED <br /> [3Yes M No 13 (Cht;dc d applicable) c (Enter an*X in the box below to indicate request,Enter a? if Preservative added <br /> Special Instructions (method,limit of detection,eta) ❑ Drinking Water <br /> I14,2+Kl+r— 2- "OAXeX 77fA4/A-9z k 4tZ ❑Collected in the s <br /> 'Explanation of Preservative State of New York , <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX! AIR VOLUME E 0Vq FOR LAB <br /> SAMPLED MEDIA (specify units) USE ONLY <br /> IWO ?a a Y,f, <br /> XP <br /> L 1iXP <br /> CRAW Relinquished by- 12:4'723 <br /> eTme1EF 1G ' Received by Date/ Time 01 <br /> OF Relinquished by 0ate/Time Received at Lab by 1 D�ft •CUSTODY Method of Shipment: Sample Condition Upon Receipt Acceptable ❑ 01bef (explain) <br /> Authorized by �� �� Date 2::2--11 <br /> (Client Signature Must Accompany Request) <br /> Pleaso return completed form and sam les to one o1 the Clayton Environmental Consultants,Inc' labs listed below <br /> DISTRIBUTION <br /> 22345 Rowhel Drive Raritan Center 400 Chastain Cent r Blvd,N W 1252 Quarry Lane WHITE Clayton Laboratory <br /> Novi,MI 48050 160 Fiekfcrest Ave Suite 490 Pleasanton,CA 94566 YELLOW - Clayton Acoounting <br /> (313)344-1770 Edison.NJ 08837 Kennesaw,GA 30144 (415)426-2600 PINK - Client Copy <br /> (201)2256040 (404)499-7500 6190 <br /> • • s <br />