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I , <br /> aw ,- IMPORTANT <br /> a Page _or _ <br /> 440 Fat Clayton use Only <br /> Clayton <br /> �` ( Gla tan Leh Pro act tJn <br /> L A 8 0 R A �(-)R y REQUEST FOR LABORATORY tate tlosutta Fioqueated �}r� �} S <br /> ! 5 F K v I C E S ANALYTICAL SERVICES Rush ChargasAuthari:ad7 o Yes No <br /> Q Phone or 0 Fa PL Aesulta <br /> Name �[ �� Clleni Job No _ �}� f, CC7 Purchase Order No _ i~ <br /> Company Rept Name _ <br /> s . []e t <br /> Marling Address (ctj_o „�_ �'_ s_ r�r kwa Sir , Z 1b � � Cornpall; P <br /> P"SPICity State ZIP �fea �>� sx+ C � - --- Adairess <br /> al <br /> Telephone No - k�L, - 'Gc,0 FAX No k7 �UiC� City S1ato,Zip <br /> Instructions and/or specific regulatory requirements Samples Bre ANALYSIS REQUESTED <br /> {mbMod 11MAl 0i tl6'ection,air) (check it alipliraole) � (t-nlnf acs X in the bqr below to indicato request Enter a P it f'ruburva ive-idded I <br /> s - a <br /> E]OFlnking Water <br /> 4Grounciv�ater oY <br /> 0 wastewater <br /> 'Explanation of Preservative rrj <br /> DATE 11ME i9ATAW Alta vptLaAE ,��,� f FOR LAH <br /> CLIENT SAMPLE IDENTIFICATION SAMPLED SAMPLED MEDIA { pei;ll)uridst �, / USE ONLY <br /> I COIJ't6d by 1 ` [print) f.OJ3ectar s Slgn7luru <br /> CHAIN Relinquished by gale/Time 4 `i/Q3 Rr_-i:eived by DatofFirnt7 <br /> OF <br /> r <br /> I i Reilnquishad by Daterrino f� �G BLeer-ed by Date/71ma <br /> Malhod of Shlprhent 1 _- — Racei4ed-It Lab 11 DBtPfTIrTSL'r �rt30 <br /> f _ <br /> UtJlilli[rl l7} - - Sample CandAiun Upon Rtceifit. ct,eplable [j Other(exp)din) <br /> 1111 _ _ Late <br /> fGrtinnl;,igiai�ru F,tI}$i fr_car;sarr t mluu:q y � _.. ..._ w....�� — <br /> Please return cornproted form and samples to one,of the Clayton Group ServJces, Inc Jams tistcd below 1,S1 I iif3Lt I It N <br /> Delrolt Regional Lab Atlanta Rogtonat lab Seatilo Regional Lab „I� - r�1147n Lant�lrft_ a <br /> 22345 Roethel drive 3360 Clis Iain Meadow„Pah way Suit©1011 4Eab E Marglnal W ry S Sulto 215 <br /> rrovi,M149375 Kennesaw GA 30144 S4 illlo,WA 99134 1 Y0110A - i,'a,7✓i A c iri r� <br /> i <br /> IBM)eas-see? teoot 232-4919 (eco/hes 1165 Pir il• t 40 it �[I k, <br /> (24S)314-1770 (7741 499 750tj NG61 783 7164 <br /> FAX 12 181 714 2655 FAX(7701 42-3 4990 FAX 1.081 763 4103 } 1 119 <br />