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Clayton For Clayton Use Only Page of .. <br />► ENVIRONMENTAL REQUEST FOR LABORATORY Project No. <br /> CONSULTANTS ANALYTICAL SERVICES Batch No. C <br /> A Marsh A Mclennan Company Ind.Code W.P. <br /> Date Logged In By - <br /> O Name A. 6,11,y1#- Title Purchase Order No. Client Job NV. <br /> CompanDept. w Name <br /> Mailing-PiAddress RCompany Dept. <br /> w <br /> City.State Zi 69 z Address <br /> Telephone No. Telefax No. City. State, Zi <br /> Date Re uRs Req.: Rush Charges Autthho�' ed? Phone/Fax Results Samples are: ANALYSIS REQUESTED <br /> S r ❑Yes LY No ❑ ❑ (Check'rf applicable) (Enter an'X'ire the box below to indicate request;E=nter a'P'if Preservative added. ' <br /> Special Instructions:(method, limit of detection, etc.) ❑ Drinking Water <br /> ❑ Collected in the 5 <br /> Explanation of Preservative: f e,l State of New York <br /> CLIENT SAMPLE IDE=NTIFICATION DATE MATRIX/ AIR VOLUME E FOR LAB <br /> SAMPLED MEDIA (specify units USE ONLY <br /> M1�-I S l-`i.5 l !.!TVe Z <br /> f1� l S-rl '3 zv o <br /> Al LO <br /> n. <br /> _ - <br /> ZBoML <br /> Collected by: �1Ll�t � (print) Collector's Signature:: <br /> CHAIN Relinquished by: Date/Time <br /> OF ,�� Received by: Dates I ime <br /> CUSTODY Relinquished by: DatelTime Received at Lab by: Date ' <br /> Method of Shipment: Sample Condition Upon eceipt: Acceptable ❑ Oth r (e&plain) <br /> Authorized by: Date <br /> (Client Signature Must Accompany Request) <br /> Please return completed form and samples to one of the Clayton Environmental Consultants, Inc. labs listed below: <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd., N.W. 1252 Quarry Lane DISTRIBUTION: <br /> Novi,MI 48375 160 Fieldcrest Ave. Suite 490 Pleasanton, CA 94566 WHITE Clayton Laboratory <br /> (313)344-1770 Edison, NJ 08837 Kennesaw,GA 30144 (510)426-2657 YELLOW - Clayton Accounting <br /> (908)225-6040 (404)499-7500 2192 <br /> PINK Client Retains <br />