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�� � For Clayton Use Qnly page of <br /> y � <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No, <br /> CONSULTANTS ANALYTICAL SERVICES Batch No. <br /> A Marsh&McLennan Company Ind. Code W.P. <br /> Date Logged In By <br /> O Name ��G C� ' Title Purchase Order No. Client J b No. <br /> company i_A Dept. w Name <br /> uJ Mailing Address UO p Company ! Dept. <br /> City,State, Zi z �' Address <br /> Q Telephone No. ITelefax No. City, State, Zi <br /> Date Results Req.: lRush Charges Authorized? Phone/Fax Results Samples are: ANALYSIS REQUESTED <br /> A.101014 �Ti ❑Yes No ❑ ❑ (check if applicable) (Enter an X in the box below to indicate request;Enter a'P'if Preservative added. ' <br /> Special Instructions: (method, limit of detection, etc.) (] Drinking Water c <br /> ❑ Collected in the 8 <br /> Explanation of Preservative: State of New York 'S 44 4j <br /> CLIENT SAMPLE IDENTIFICATION FSAMPLED <br /> MATRIX/ AIR VOLUME pQ•�\ � FOR LAB <br /> MEDIA (specify units Z 9 <rl USE ONLY <br /> s — t <br /> Collected by: %ta'C s V (print) Collector's Signature: <br /> CSN Relinquished by:� � D�/T'me LS3� Received by: Date/Time <br /> CUSTODY Relinquished by: Date/Time Received at Lab by: Dat ' e 3- <br /> Method of Shipment: Sample Condition Upon Receipt. 'Acceptable r] erf(explain) <br /> Authorized by: Z4�x'_4 Lf Date !T_ <br /> (Client Signature Must Accompany Request) <br /> Please return completeflorm and samples to one of the CI_a_ on Environmental Consultants Inc, fabs listed below: <br /> "'— <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd., M.W. 1252 Quarry Lane DISTRIBUTION: <br /> - Clayton Laboratory <br /> Novi, M!48375 160 Fieldcrest Ave. Suite 490 Pleasanton, CA 94566 YELLOW - Clayton(313)344-1770 Edison, NJ 08837 Kennesaw,GA 30144 (510)426-2657 PINK Client Accounting <br /> (908)225-6040 (404)499-7500 2/92 <br />