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Clayton For Clayton Use Only Page of <br /> ENVIRONMENTAL REQUEST FOR LABORATORY Project No. r <br /> CONSULTANTS ANALYTICAL SERVICES Batch No. 90101 <br /> A Marsh 6 Mclennan Company Client No. <br /> Date Logged In By <br /> O Name [� Title ,Q 7 Purchase Order No. Client Job No. <br /> o ff Company i L Dept. w Name <br /> w Mailing Address 1A Z C.la A1Z v Company <br /> Cc w City, State, Zip S Q 4 Address <br /> ¢ Telephone No. S'7 1 Telefax No. 19.3 ?u ? City, State, Zi <br /> Date esult Required:I Rush Ch4tgses Authorized? Phone Resu Samples are: ANALYSIS REQUESTED <br /> [�'y (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 deter n, etc.) ❑ Drinking Water <br /> /,a <br /> ❑ Collected in the 8 <br /> Explanation of Prelive: V State of New York o O <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME EFOR LAB <br /> SAMPLED MEDIA (specify units) Z USE ONLY <br /> CHAIN Relinquished by: Dat !Ti 1- <br /> 3O Received by: DatefT'ime <br /> OF <br /> CUSTODY Relinquished by: Dale/Titne Received at Lab by: Date 90 <br /> Method of,4hipmenjfl, Sample Condition Upon Receipt: [� Acceptable ❑ Other (explain) <br /> Authorized by: Date <br /> (Client Ygndfure Must Accompany Request) <br /> Please return completed form and samples to one of the Clayton Environmental Consultants Inc labs listed below: <br /> DISTRIBUTION: <br /> 22345 Roethel Drive Raritan Center 400 Chastain Center Blvd., N.W. 1252 Quarry Lane WHITE Clayton Laboratory <br /> Novi, MI 48050 160 Fieldcrest Ave. Suite 490 Pleasanton, CA 94566 YELLOW Cla�gon Accounting <br /> (313)344-1770 Edison, NJ 08837 Kennesaw,GA 30144 (415)426-2600 PINK Client Copy <br /> 12n11 22r-Fnen renes 4()q-75nn C/O() <br />