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w <br /> �..'.�' .` 7 irk �� I— ri l� r—. r'" t` tI [Ind. <br /> Clayton—ffse On Page�� <br /> C�dy�ur <br />' REQUEST FOR LABORATORY ect No. S gyp. <br /> ENVIRONMENTAL ANALYTICAL SERVICES h No. <br /> CONSULTANTS X06 <br /> A Marsh a Mclennan Company Coda W.P. <br /> Logged In By <br /> O Name 4{ L- Tdle Purchase Order No. Client J <br /> f amInny tgt, IDept. jSk W Name <br /> j MailingAddress U Company De t. <br /> City. State,Zi Address p <br /> Telephone No. ITelelax No. z Citv,State ZIP 7Z40V <br /> Date Results Req. I Rush Charges Autthopp'zed? Phone/Fax Results Samples are: 'ANALYSIS REQUESTED <br /> 13 Yes W% ❑ 13 (check if applicable) 0 (Enter an'X'in the box be.lVv to indicate request;Enter a'P'9 Preservative added. " <br /> Special Instructions: (method, limit of detection, etc.) ❑ Drinking Water <br /> ❑ Collected in the ;' <br /> ' Explanation of Preservative: L State of New York �, <br /> j CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME 2 A \�� FOR LAB <br /> SAMPLED MEDIA (specify units Z �l` USE ONLY <br /> 1Af <br /> Tek L- <br /> tn1 #1WL1 a�A <br /> 1K L Z <br /> L — -- — <br /> I <br /> I . <br /> i Collected by: (print) Collector's Signatur <br /> � �l L(./ f <br /> CHAIN Relinquished by: /rt fA L(,� D to/T1 e <br /> OF 7 l I�7b15 L �3�►p Received by: Date/Time <br /> CUSTODY Relinquished by: Date/1 ime Received at.tab by: Date i <br /> Method of Shipment: Sample Condition Upon eoelpt: W-Acceptable [:I Otfie (ex Iain) <br /> j Authorized by: Date <br /> (Client Signature Must Accompany Request) <br /> Please return completed form and samples to one of the Cla on Environmental Consultants, Inc. labs listed below: <br /> 22345 Roethef Drive Raritan Center 400 Chastain Center Blvd., N.W. 1252 Ouairy Lane DISTRIBUTION: <br /> - Clayton LaboratoryNovi, MI 49375 160 Fieldcrest Ave. Suite 490 Pleasanton, CA 94566 YELLOW Clayton Accounting <br /> (313)344-1770 Edison, NJ 08837 Kennesaw,GA 30144 (510)426-2657 <br /> (908)225-6040 (404)499-7500 2192 PINK Client Retains <br /> i <br />